Assignment: Week 5 Focused Exam Cough Template

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Assignment: Week 5 Focused Exam Cough Template

Assignment: Review the DCE (Shadow Health) Documentation Template for Focused Exam

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.
  • 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?
  • Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing tReview 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.
    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?

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Review the DCE (Shadow Health) Documentation Template for Focused Exam Assignment: Week 5 Focused Exam Cough Template

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Assignment: Week 5 Focused Exam Cough Template

Review the DCE (Shadow Health) Documentation

 

 

 

 

 

 

 

HeShadow Health Focused Exam: Cough
Subjective Data Collection: 20 of 20 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
• Found:
Indicates an item that you found.
• Available:
Indicates an item that is available to be found.
Category
Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint

Finding:
Established chief complaint

Finding:
Reports cough
(Found)
Pro Tip: Asking about the characteristics of your patient’s cough and voice quality should guide your assessment.
Example Question:
Do you have a cough?
History of Present Illness

Finding:
Asked about onset of cough

Finding:
Reports cough started 5 days ago
(Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem.
Example Question:
How long have you had a cough?

Finding:
Asked about frequency and duration of cough

Finding:
Reports coughing every couple minutes
(Found)
Pro Tip: Establishing a timeline for Danny’s coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
How frequently have you been coughing?

Finding:
Asked about character of cough

Finding:
Reports cough is wet
(Found)
Pro Tip: Asking about the characteristics of your patient’s cough and voice quality should guide your assessment.
Example Question:
Is your cough a wet cough?

Finding:
Reports clear sputum with cough
(Found)
Pro Tip: Asking if your patient’s cough is productive should guide your assessment.
Example Question:
Do you produce any phlegm or sputum with your cough?

Finding:
Asked about aggravating factors for cough

Finding:
Reports cough is worse at night
(Found)
Pro Tip: Establishing a timeline for Danny’s coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
Is your cough worse at night?

Finding:
Reports exposure to secondhand smoke
(Found)
Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking about all types of tobacco products assesses this risk factor.
Example Question:
Do you smoke?

Finding:
Reports not knowing specific triggers that make the cough worse
(Found)
Pro Tip: Follow-up questions will enable Danny to more fully and specifically describe his condition, experience, or symptoms. Establishing what makes Danny’s cough worse will allow you to more effectively treat his symptoms.
Example Question:
What makes your cough worse?

Finding:
Asked about relieving factors for cough

Finding:
Reports cough “stays the same” with rest
(Found)
Pro Tip: Asking what relieves the patient’s chief complaint will determine the efficacy of possible treatment and may provide important insight into the condition itself.
Example Question:
Does resting help your cough?

Finding:
Reports cough “stays the same” despite drinking water
(Found)
Pro Tip: Asking what relieves the patient’s chief complaint will determine the efficacy of possible treatment and may provide important insight into the condition itself.
Example Question:
Does drinking water help your cough?

Finding:
Asked about nasal symptoms

Finding:
Reports current runny nose
(Found)
Pro Tip: Asking your patient if his nose is running will allow you to determine the symptoms he is experiencing and possible triggers.
Example Question:
Do you have a runny nose?

Finding:
Denies sneezing
(Found)
Pro Tip: Asking your patient if he has been sneezing will allow you to determine the symptoms he is experiencing and possible triggers.
Example Question:
Have you been sneezing?

Finding:
Reports frequent rhinorrhea
(Found)
Pro Tip: Establishing how frequently your patient experiences symptoms, like a runny nose, will most effectively enable you to treat your patient’s symptoms.
Example Question:
Do you get runny noses often?

Finding:
Followed up on nasal discharge

Finding:
Reports nasal discharge is clear
(Found)
Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like the character of his nasal discharge, will help you to understand his symptoms.
Example Question:
What color is your snot?

Finding:
Reports nasal discharge is thin
(Found)
Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like the character of his nasal discharge, will help you to understand his symptoms.
Example Question:
Is your snot thin?

Finding:
Asked about ear symptoms

Finding:
Reports pain in right ear
(Found)
Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Danny if he has ear pain might indicate a possible ear infection and a reason for changes in his hearing.
Example Question:
Do you have any ear pain?

Finding:
Followed up on ear pain

Finding:
Reports ear pain started yesterday
(Found)
Pro Tip: It is important to know how long your patient has suffered pain to determine how urgently treatment is needed.
Example Question:
How long have you had ear pain?

Finding:
Reports pain rating of 3 for ear pain
(Available)
Pro Tip: It is important to determine the severity of your patient’s paint to determine how urgently treatment is needed and how best to address it.
Example Question:
How bad is your ear pain?

Finding:
Denies ear discharge
(Found)
Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has ear discharge, will help you to understand his symptoms.
Example Question:
Do you have any ear discharge?

Finding:
Asked about throat symptoms

Finding:
Reports sore throat
(Found)
Pro Tip: Asking about the patient’s mouth and throat should guide your assessment.
Example Question:
Is your throat sore?

Finding:
Reports “a little” pain with swallowing
(Found)
Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has ear discharge, will help you to understand his symptoms.
Example Question:
Does it hurt when you swallow?  argument.

Episodic/Focused SOAP Note Exemplar

Focused SOAP Note for a patient with chest pain

S. CC: “Chest pain”  HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years  ROS    General–Negative for fevers, chills, fatigue Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema  Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis

O.

VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

General–Pt appears diaphoretic and anxious

Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the

second right inter-costal space which radiates to the neck.

A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.

Gastrointestinal–The abdomen is symmetrical without distention; bowel

sounds are normal in quality and intensity in all areas; a

bruit is heard in the right para-umbilical area. No masses or

splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary— Lungs are clear to auscultation and percussion bilaterally

Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)

A.

Differential Diagnosis:

1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

2) Angina (provide supportive documentation with evidence based guidelines).

3) Costochondritis (provide supportive documentation with evidence based guidelines).

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

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