Pediatric Cough Shadow Health For Danny Rivera
Documentation / Electronic Health Record
- Document: Vitals
- Document: Provider Notes
Document: Vitals
| Vitals | |
| Blood Pressure | 120/76 |
| O2 Sat | 96 |
| Pulse | 100 |
| Resp. Rate | 28 |
| Temperature | 37.2C |
Documentation / Electronic Health Record
Document: Vitals
Document: Provider Note
Document: Provider Notes
| Student Documentation | Model Documentation |
| SubjectiveDanny Rivera is an 8 year old male patient who reports to have had a cough for the last 4 to 5 days. He reports the cough is worse at night and makes him not sleep well and also gets fatigued. He describes the cough as watery. He also has a running nose. He has mild soreness in his throat which he relieves with over the counter drugs. He had ear infections when young and had pneumonia in the past. He denies any headache, dizziness, fever, sputum, chest pain , abdominal pain or breathing problems. His cough does not get worse when he is active. | Return to Canvas to complete your SOAP note for this assignment. Pediatric Cough Shadow Health for Danny Rivera |
Focused Exam on Danny Rivera cough in Shadow Health Sample Paper
Health history and physical examination are integral in diagnosing patients. The questions asked during the two procedures determine the outcome and diagnosis made during an assessment. Nurses must be keen when taking the health history so that they do not miss important patient health details. This essay analyzes essential questions for a patient in health history and physical examination that informed a diagnosis and necessary confirmatory diagnostic tests.
The crucial questions include what is the duration of the cough? The question helps differentiate between chronic and acute cough because they have different etiologies. What are the cough characteristics? The severity, intensity, and characteristic of the sputum help determine the underlying cause. In this case, thick phlegm could indicate other problems such as tuberculosis.
A prolonged dry cough could be indicative of other problems such as asthma and pertussis (O’Grady et al., 2017). What are the aggravating and relieving factors? The question helps determine an already working therapy and informs patient education. They also help rule out other respiratory problems such as allergies
Have you had exposure to people with similar symptoms? Exposure to sick individuals coupled with poor hygiene leads to infection with communicable diseases. What are the associated symptoms? Different diseases have different symptoms associated with cough, and in this case, the symptoms are synonymous with PNA. Are you active? Diseases affect an individual’s activity level depending on the severity and virulence of the disease-causing microorganism.
Do you have ear problems? Ear, nose, and throat infections are often synonymous and quickly spread among the three organs. Family history of respiratory illnesses is another vital question. Some diseases carry some genetic predisposition, such as cystic fibrosis (Haga & Orlando, 2020). Family history helps rule out some of these diseases.
Diagnostic studies are integral as adjunct or confirmatory tests for specific diagnoses. These tests include radiologic and blood tests (Kosack, Page, & Klatser, 2017). The most common tests are blood tests. In this case, a complete blood count with white blood cells differentials is an important diagnostic test. A chest X-ray is also required to check for inflammation of the lungs. Pulse oximetry readings are also essential to determine if the patient is in any respiratory distress. These diagnostic tests also help determine severity of a disease and thus, inform treatment and other interventions.
Health history taking and physical examination reveal much information, as seen above. Nurses must be proactive in health history taking because it contains valuable health information. In addition, diagnostic tests are necessary in many conditions. The diagnostic tests also inform patient management, as seen.
References
- Haga, S. B., & Orlando, L. A. (2020). The enduring importance of family health history in the era of genomic medicine and risk assessment. Personalized Medicine, 17(3), 229-239. https://doi.org/10.2217/pme-2019-0091
- Kosack, C. S., Page, A. L., & Klatser, P. R. (2017). A guide to aid the selection of diagnostic tests. Bulletin of the World Health Organization, 95(9), 639. doi: 10.2471/BLT.16.187468
- O’Grady, K. A. F., Drescher, B. J., Goyal, V., Phillips, N., Acworth, J., Marchant, J. M., & Chang, A. B. (2017). Chronic cough postacute respiratory illness in children: a cohort study. Archives of Disease in Childhood, 102(11), 1044-1048. http://dx.doi.org/10.1136/archdischild-2017-312848
