Cough Documentation

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation SUBJECTIVE DATA: Cough Chief Complaint (CC): Cough History of Present Illness (HPI): This is an 8-year-old Puerto Rican male, who was brought in today by his grandmother with a persistent productive cough that started about 4-5 days ago. He reports a mild sore throat, rates pain 2/10, food and liquid do not make a difference in his cough. He denies trauma or sick contacts. No fever or muscle aches. He reports a runny nose with clear drainage, with mild throat soreness that he rates a 2/10. He has a productive cough with clear sputum, that keeps him up at night, he also reports right ear pain. He states his mother gave him “purple” cough syrup, but it helped minimally. He denies fever, chills, body aches and has no change in appetite or ability to swallow. He also denies sick contacts and reports he washes his hands frequently. Medications: Daily multivitamin; cough syrup (purple?) Allergies: None Past Medical History (PMH): Frequent ear infections as a toddler, last one around 2 years old; Pneumonia 2020 (treated at urgent care clinic) Past Surgical History (PSH): No surgical history or prior hospitalizations Sexual/Reproductive History: Personal/Social History: Danny is in the 3rd grade, missed 2 weeks of school last year due to pneumonia. He lives with is mother, father who work during the day and his grandmother provides child-care while parents work. English is the primary language spoken in the home, however some Spanish is used. Immunization History: Current and up to date with all age appropriate vaccinations. No flu vaccine in the last 12 months. Significant Family History: Mother: type 2 diabetes, HTN, hypercholesterolemia, spinal stenosis, obesity. Father: smoker, HTN, hypercholesterolemia, asthma as a child. Maternal grandmother: type 2 diabetes, HTN. Maternal grandfather: smoker, eczema. Paternal grandmother: died at age 52 in a car accident. Paternal grandfather: history unknown. Review of Systems: General: Breathing non labored, afebrile, coughs every few seconds, cough is dry, coarse and non-productive, while in clinic. HEENT: Positive for R ear pain, slight sore throat Respiratory: Positive for productive cough with clear sputum, Cardiovascular/Peripheral Vascular: Denies chest pain, no murmurs or rubs, no dyspnea Psychiatric: Denies being sad or feeling anxious Neurological: Denies seizures, syncope, no head trauma reported Lymphatics: Denies blood transfusions, denies anemia OBJECTIVE DATA: Physical Exam: Vital signs: 37.2, 120/76, 100, 28, 96% on RA, 4’2”, 90 lbs., BMI General: This is a well-developed, well nourished 8 year old Puerto Rican boy who is alert and cooperative. He is a good historian and answers all health questions appropriately. He coughs every few minutes but is no distress. HEENT: Normocephalic, face symmetrical. No ptosis, eyelid edema, lesions or allergic shiners; sclera white; conjunctiva pink and moist, no drainage. Right tympanic membrane erythemic, bulging, cone of light 5:00, left ear pearly gray, cone of light 7:00, no drainage, erythema Nasal cavities pink with clear discharge noted, turbinates with decreased patency. Respiratory: Chest symmetrical with respirations, no wheezing, crackles or other adventitious lung sounds. Cardiology: RRR, no murmurs, or rubs Lymphatics: No bruising or bleeding, no lymphadenopathy, no Psychiatric: No depressed or sad mood, no anxiety. Mood calm and appropriate. Diagnostics/Labs: Chest x-ray, throat swab to rule out strep throat, sputum culture and CBC. ASSESSMENT: Priority Diagnosis: Common Cold caused by Rhinovirus: Belonging to the Enterovirus (EV) genus, is the most common cause of upper respiratory infections, like the common cold (Royston & Tapparel, 2016). Rhinovirus causes sneezing, throat irritation, rhinorrhea or runny nose, and ear and sinus tract inflammation and irritation (Vundavalli, 2018). Onset of symptoms usually occurs 1-2 days after becoming infected and can last up to 14 days (Vundavalli, 2018). The symptoms are usually accompanied by general fatigue and malaise, muscle aches, and fever (Vundavalli, 2018). Generally, treatment is centered around symptoms and can be managed with OTC medications like acetaminophen and cough syrup (Vundavalli, 2018). This diagnosis is supported by the history and physical completed by the NP. The patient symptoms and the clinical evidence reported support this diagnosis over the differential diagnoses presented below. Differential Diagnoses Acute Sinusitis: Also known as rhinosinusitis, is an acute inflammation of the sinuses (DeBoer & Kwon, 2021). Acute sinusitis typically has a viral etiology, including the influenza virus or rhinovirus, but can also be caused by bacterial pathogens, like Streptococcus pneumoniae or H. influenzae (DeBoer & Kwon, 2021). Obtaining a complete history and physical is vital in the reaching a diagnosis. A clinical diagnosis can be confidently made when a patient presents with three cardinal symptoms, they are: purulent nasal drainage with coupled with either nasal obstruction or facial pain/pressure/fullness (DeBoer & Kwon, 2021). The diagnosis is not supported by the evidence, the patient does not have the three cardinal symptoms that would support this diagnosis. Allergic Rhinitis (AR): A common disorder closely linked to asthma and conjunctivitis involves a myriad of symptoms, including, nasal congestion, nasal itching, rhinorrhea, and sneezing (Small et al., 2018). It is the most common form of rhinitis and affects around 20% of the population annually. AR impacts one’s quality of life, disturbing sleep, work and home productivity and social interaction. Formerly categorized as “seasonal” allergies, allergic rhinitis is currently classified based on the duration and severity of symptoms: intermittent or persistent and mild or moderate to severe (Small et al., 2018). Allergic rhinitis is a symptomatic response to allergen exposure due to the IgE-mediated inflammation of membranes that line the nose (Varshney & Varshney, 2015). To assess for this condition, clinicians should perform and complete a thorough history and physical, which includes identifying specific hallmark symptoms of AR, as described above. A trial of antihistamine or nasal glucocorticoid steroid aids in the diagnosis of AR, however, skin allergen tests provide a definitive and more specified clinical diagnosis (Small et al., 2018). This patient’s clinical symptoms are not suggestive of AR, he does not report nasal itching, nasal congestion, nor sneezing. He has rhinorrhea, however, this is not sufÏcient evidence to support this diagnosis. Bronchitis: A condition in which the bronchial tubes (airways of the lungs) become inflamed and mucusfilled, causing coughing. It can be acute or chronic and is often precipitated by a common cold or the flu (National Heart, Lung, and Blood Institute, n.d.). Bronchitis also causes shortness of breath, wheezing, chest tightness and a low-grade fever (Medline Plus, 2021). The patient does not present with shortness of breath, wheezing, chest tightness nor a low-grade fever. The clinical evidence does not support this diagnosis.