NURS 6512 Week 5 DCE Assignment 2: Digital Clinical Experience: Focused Exam: Cough

NURS 6512 Week 5 DCE Assignment 2: Digital Clinical Experience: Focused Exam: Cough

NURS 6512 Week 5 DCE Assignment 2: Digital Clinical Experience: Focused Exam: Cough

Week 5:
Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): “I have been coughing a lot.”
History of Present Illness (HPI):
Danny Rivera is an 8-year-old Puerto Rican boy that presented to the Shadowville Elementary nurse’s office with complaints of cough. He provides subjective data about his health problem. He is responsive and answers appropriately the questions asked during the assessment. Danny reports that he has been coughing a lot for the last three days. The cough is wet, productive, leading to slimy clear phlegm. The cough worsens at night affecting his sleep, as he reports he did not get enough sleep the previous night. The cough lasts a few seconds.

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Danny resides in the same house with his grandfather who is a smoker, exposing him to cigar smoke. Danny reports that her mother gave her a table spoonsful of a purple-ish medicine, which soothed his cough. He has no history of using any home remedies for cough. He recently took syrup prescribed by his doctor for cough. He takes multivitamins daily. Danny is usually physically active. However, the cough has reduced his ability to engage in active physical activity, as he feels fatigued. The cough has also affected his ability to concentrate in class since he does not get enough sleep at night. Danny also reported worsening running nose ever since the cough started. The patient reports sore throat but denies sneezing.
Medications: Danny reports that his mother gave him a purple-ish medicine to sooth his cough this morning. He is not on any other medication.
Allergies: Danny does not have any history of food, drug, or environmental allergic reactions.
Past Medical History (PMH): Danny has a history of pneumonia. He also has a frequent experience of cold, since his rose is runny most of the times.
Past Surgical History (PSH):Danny has no history of surgeries
Sexual/Reproductive History: Danny is an 8-year-old boy with unremarkable sexual or reproductive history.
Personal/Social History: Danny resides with his mother and grandfather. He is a student. He likes engaging in active physical activity. His grandfather smokes cigarette, exposing him to harmful smoke at home.
Immunization History: Danny’s immunization history is up-to date.
Significant Family History (Include history of parents, Grandparents, siblings, and children): There is a history of asthma (his grandfather).
Review of Systems:
General: The patient is alert, responsive, and answers asked questions appropriately. He reports fatigue and denies fevers and chills.
HEENT: Danny denies headache, vision changes, dizziness, watery eyes, eye redness, eye pain, and sinus pain. The patient reports sore throat, running nose, and itchy nose at times.
Respiratory: The client denies difficulty in breathing. He reports wet productive cough. He also reports occasional sneezing
OBJECTIVE DATA:
Physical Exam:
Vital signs: Not given
General: The patient is alert and oriented to self, place time. He is well groomed for the occasion.
HEENT: The sclera is white with most and pink conjunctiva with no discharge. The nasal cavities are pink with clear discharge. The turbinate is patent. The ears have no abnormal visible findings with cone of light being 7.00, no discharge, and tympanic membranes being pearly grey. The oral mucosa appears moist and pink with erythematous tonsils. The posterior oropharynx appears pink with cobble stoning in the posterior oropharynx texture. There is no postnasal drip.
Respiratory: The breath sounds are present in all the areas with absent adventitious sounds. The lung sounds are clear with fremitus symmetrical bilaterally. Lung function tests: : FEV1: 1.549 L, FVC 1.78 L (FEV1/FVC: 87%)
Cardiology: Auscultation of the bronchoscopy negative with no extra sounds. There is resonance on chest wall percussion with no dullness.
Lymphatics: No lymphadenopathy
Diagnostics/Labs: The additional laboratory and diagnostic investigations needed to develop diagnoses include nasal culture and chest x-ray should the patient demonstrate worsening symptoms. The chest x-ray may be needed to rule out other causes such as tuberculosis and pneumonia if the symptoms worsen.
ASSESSMENT:
Danny’s priority diagnosis is common cold. Common cold is a term used to refer to mild upper respiratory illness. The disease has viral origin. It is self-limiting disease that mainly affects the upper respiratory tract. In severe cases, patients may develop spread of the viral infection to other organs and complications such as those caused by the bacteria. Patients affected by common cold present the hospital with complaints that include sneezing, nasal discharge and stuffiness, sore throat, cough, and fatigue. The additional symptoms that patients may exhibit include hoarseness, headache, lethargy, and myalgia. The symptoms often last between 1 and 7 days with them peaking within 2-3 days of the infection (Ibrahim et al., 2021; Montesinos-Guevara et al., 2022; Wilson & Wilson, 2021). Danny has present with symptoms that align with those of common cold. For example, he complains of cough, sore throat, and running nose for the last three days, hence, common cold being his primary diagnosis.
Danny’s secondary diagnosis is rhinosinusitis. Rhinosinusitis is a disorder characterized by the inflammation of the nasal cavities and passages. Patients develop this condition following their exposure to potential causes such as smoke, lowered immunity, and asthma. Patients often report symptoms such as nasal congestion, toothache, loss of smell, halitosis, postnasal drip, and runny nose (Chandy et al., 2019; Utkurovna et al., 2022). Danny is frequently exposed to tobacco smoke, which may have led to the development of rhinosinusitis. However, the absence of additional symptoms such as postnasal drip, toothache, loss of smell, and sinus pain or pressure, makes rhinosinusitis the least likely cause of his problem.
The last differential diagnosis that should be considered for the patient is whooping cough or pertussis. Pertussis is a disorder of the upper respiratory system that is characterized by severe hacking cough accompanied by whooping breath sounds. The disease is highly contagious and requires immediate patient isolation to prevent its spread in the population. The symptoms associated with whooping cough include cough, fever, red, watery eyes, nasal congestion, and runny nose. The affected populations are increasingly predisposed to complications such as pneumonia, seizures, brain damage, and dehydration (Zhang et al., 2020). However, pertussis is Danny’s least likely diagnosis because of the lack of hacking, whooping cough and red, watery eyes.

References
Chandy, Z., Ference, E., & Lee, J. T. (2019). Clinical Guidelines on Chronic Rhinosinusitis in Children. Current Allergy and Asthma Reports, 19(2), 14. https://doi.org/10.1007/s11882-019-0845-7
Ibrahim, A. E., Elmaaty, A. A., & El-Sayed, H. M. (2021). Determination of six drugs used for treatment of common cold by micellar liquid chromatography. Analytical and Bioanalytical Chemistry, 413(20), 5051–5065. https://doi.org/10.1007/s00216-021-03469-3
Montesinos-Guevara, C., Buitrago-Garcia, D., Felix, M. L., Guerra, C. V., Hidalgo, R., Martinez-Zapata, M. J., & Simancas-Racines, D. (2022). Vaccines for the common cold. Cochrane Database of Systematic Reviews, 12. https://doi.org/10.1002/14651858.CD002190.pub6
Utkurovna, S. G., Farkhodovna, S. Z., &Furkatjonovna, B. P. (2022). OPTIMIZATION OF THE TREATMENT OF ACUTE RHINOSINUSITIS IN CHILDREN. Web of Scientist: International Scientific Research Journal, 3(3), Article 3. https://doi.org/10.17605/OSF.IO/GYBM7
Wilson, M., & Wilson, P. J. K. (2021). The Common Cold. In M. Wilson & P. J. K. Wilson (Eds.), Close Encounters of the Microbial Kind: Everything You Need to Know About Common Infections (pp. 159–173). Springer International Publishing. https://doi.org/10.1007/978-3-030-56978-5_10
Zhang, J.-S., Wang, H.-M., Yao, K.-H., Liu, Y., Lei, Y.-L., Deng, J.-K., & Yang, Y.-H. (2020). Clinical characteristics, molecular epidemiology and antimicrobial susceptibility of pertussis among children in southern China. World Journal of Pediatrics, 16(2), 185–192. https://doi.org/10.1007/s12519-019-00308-5

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Digital Clinical Experience: Focused Exam: Cough

In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

Resources

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Chapter 11, “Head and Neck”

This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.

Chapter 12, “Eyes”

In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.

Chapter 13, “Ears, Nose, and Throat”

The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 15, “Earache”

Download Chapter 15, “Earache”

This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.

Chapter 21, “Hoarseness”

Download Chapter 21, “Hoarseness”

This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.

Chapter 25, “Nasal Symptoms and Sinus Congestion”

Download Chapter 25, “Nasal Symptoms and Sinus Congestion”

In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.

Chapter 30, “Red Eye”

Download Chapter 30, “Red Eye”

The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.

Chapter 32, “Sore Throat”

Download Chapter 32, “Sore Throat”

A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.

Chapter 38, “Vision Loss”

Download Chapter 38, “Vision Loss”

This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.

Note: Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.

Document: Episodic/Focused SOAP Note Exemplar

Download Episodic/Focused SOAP Note Exemplar (Word document)

Document: Episodic/Focused SOAP Note Template

Download Episodic/Focused SOAP Note Template (Word document)

Document: Midterm Exam Review

Download Midterm Exam Review (Word document)

Shadow Health Support and Orientation Resources

Shadow Health. (2021). Welcome to your introduction to Shadow Health

Links to an external site.. https://link.shadowhealth.com/Student-Orientation-Video

Shadow Health. (n.d.). Shadow Health help desk

Links to an external site.. Retrieved from https://support.shadowhealth.com/hc/en-us

Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students.

Download Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide

Document: DCE (Shadow Health) Documentation Template

Download DCE (Shadow Health) Documentation Template for Focused Exam: Cough (Word document)

Use this template to complete your Assignment 2 for this week.

Required Media

Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 (29m)

Online media for Seidel’s Guide to Physical Examination

It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 10, 11, and 12 that relate to the assessment of the head, neck, eyes, ears, nose, and throat. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.

Geeky Medics. (2020, June 5).Fundoscopy (Ophthalmoscopy)

Links to an external site. – OSCE guide [Video]. YouTube. https://www.youtube.com/watch?v=SVuP5Td23AQ&feature=youtu.be

Health4TheWorld Academy Videos Channel. (2020, February 15).Paranasal sinus imaging

Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=8TQBtdbEY-I

University of Iowa Ophthalmology. (2016, December 19).Fluorescein staining of the cornea

Links to an external site.. Retrieved from https://vimeo.com/198695974

Credit Line: University of Iowa Ophthalmology. (n.d.). Fluorescein staining of the cornea [Video file]. Retrieved from ​https://vimeo.com/198695974. The author(s) and publishers acknowledge the University of Iowa and EyeRounds.org for permission to reproduce this copyrighted material.

Note: Approximate length of this media program is 25 seconds.

Optional Resources

Hayashi, T., Kitamura, K., Hashimoto, S., Hotomi, M., Kojima, H., Kudo, F., Maruyama, Y., Sawada, S., Taiji, H., Takahashi, G., Takahashi, H., Uno, Y., & Yano, H. (2020). Clinical practice guidelines for the diagnosis and management of acute otitis media in children—2018 update

Links to an external site.. Auris Nasus Larynx, 47(4), 493–526. https://doi.org/10.1016/j.anl.2020.05.019

Mustafa, Z., & Ghaffari, M. (2020). Diagnostic methods, clinical guidelines, and antibiotic treatment for Group A streptococcal pharyngitis: A narrative review

Links to an external site.. Frontiers in Cellular and Infection Microbiology, 10. https://doi.org/10.3389/fcimb.2020.563627

Patel, G. B., Kern, R. C., Bernstein, J. A., Hae-Sim, P., & Peters, A. T. (2020). Current and future treatments of rhinitis and sinusitis

Links to an external site.. The Journal of Allergy and Clinical Immunology: In Practice, 8(5), 1522–1531. https://doi.org/10.1016/j.jaip.2020.01.031

Links to an external site.

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.

Chapter 7, “The Head and Neck”

This chapter describes head and neck examinations that can be made with general clinical resources. Also, the authors detail syndromes of common head and neck conditions.

To Prepare

Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.

Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.

Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.

Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.

Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Focused Exam: Cough Assignment:

Complete the following in Shadow Health:

Respiratory Concept Lab (Required)

Episodic/Focused Note for Focused Exam: Cough

HEENT (Recommended but not required)

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.

submission information

Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Canvas.

Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Canvas for your faculty review.

(Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-passLinks to an external site.

Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link below.

To submit your completed assignment, save your Assignment as WK5Assgn2+last name+first initial.

Then, click on Start Assignment near the top of the page.

Next, click on Upload File and select both files and then Submit Assignment for review.

By submitting this assignment, you confirm that you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.