NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
Walden University NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
The introduction for the Walden University NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
How to Write the Body for NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
After the introduction, move into the main part of the NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.
Stuck? Let Us Help You
Completing assignments can sometimes be overwhelming, especially with the multitude of academic and personal responsibilities you may have. If you find yourself stuck or unsure at any point in the process, don’t hesitate to reach out for professional assistance. Our assignment writing services are designed to help you achieve your academic goals with ease.
Our team of experienced writers is well-versed in academic writing and familiar with the specific requirements of the NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough assignment. We can provide you with personalized support, ensuring your assignment is well-researched, properly formatted, and thoroughly edited. Get a feel of the quality we guarantee – ORDER NOW.
Sample Answer for NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
Patient Particulars
Name: Danny Rivera
Age: 8years
Gender: male
Subjective Data
Chief Complaint: coughing for five days
History of Present Illness (HPI): Danny Rivera is an 8 years old male who reports having a productive cough. The cough is of acute onset, work triggers the cough, and it is worse at night such that it keeps him awake. The cough is gurgly and watery associated with fatigue, pain in the right ear, running nose, and throat soreness. However, he denies fever, headache, dysphagia, nosebleed, phlegm, sputum, chest pain, trouble breathing, and abdominal pain.
Medications: over the counter drugs to relieve sore throat
Allergies: the patient is allergic to fur, cold air, dust, and smoke. He develops hives after coming into contact with fur. However, he denies food and drug allergies.
Past Medical History (PMH): the patient had an ear infection and pneumonia in the past. He denies hospital admission and blood transfusion.
Past Surgical History (PSH): he denies major and minor surgical procedures
Personal/Social History: the child is in grade two. He performs exemplary well in his classwork and extra-curricular activities. He relates well with his teachers, parents, siblings, and playmates. The child enjoys reading and playing soccer.
Immunization History: the child’s immunization schedule is up to date. His last tetanus vaccine was six months ago. He is due for the influenza vaccine in two months.
Family History: The patient is the firstborn in his family. He has a younger sister who is two years old. His parents
are alive. His 34 years old father has asthma and diabetes. His mother is healthy and takes care of the family. His 60years old paternal grandfather is asthmatic. His paternal grandmother has had COPD for five years due to tobacco use. His maternal grandparents are alive and healthy. There is no history of cancer, mental health illnesses, kidney disease, and heart disease.
Review of Systems
General: the child denies weight loss, night sweats, and fever
HEENT: The patient denies headache and dizziness. He reports tearing and itchiness of the eyes. However, he denies blurring of vision, hearing problems, and painful ears.
Respiratory: the patient has a productive cough. However, he denies chest pain, wheezing, fast breathing, sputum production, and hemoptysis.
Cardiovascular/Peripheral Vascular: the patient denies dyspnea, syncope, lower limb swelling, orthopnea, and paroxysmal nocturnal dyspnea.
Psychiatric: the child denies hallucinations, suicidal ideation, sadness, hopelessness, and insomnia.
Neurological: the child denies numbness, paralysis, facial droop, and tingling sensation.
Lymphatics: the patient denies swollen arms and legs, recurring infections, skin fibrosis, and lymph nodes.
Objective Data
Vital signs: temperature is at 37.8 degrees Celsius, blood pressure at 98/68mmHg, the pulse rate at 88beats per minute, pulse oximetry at 98%, and respiratory rate at 36 breaths per minute.
General: the patient has a healthy body weight and height for his age. He is well-kempt, alert, and oriented. He is sitting on the bench calmly through coughing constantly. He appears to be fatigued but stable.
HEENT: the patient has moist mucus membranes. He has swollen, dull, and watery eyes with pink conjunctiva. The patient has a clear nasal discharge with Redness and cobblestoning in the back of the throat. The Right Tympanic membrane is red inflamed. Right cervical lymph node enlarged with reported tenderness.
Respiratory: the patient has an increased respiratory rate with no acute respiratory distress. The chest expansion is symmetrical with no swelling and scar. There is a resonant percussion note with clear breath sounds are to auscultation. There is a negative bronchophony.
Cardiology: the heart is at the 5th ICS MCL. They hear sounds S1 S2 are present. There are no murmurs, gallops, or rubs.
Lymphatics: the patient does not have lower limb edema, erythema, splenomegaly, and red streaks.
Psychiatric: the patient is calm and oriented to time, place, and person. His speech is steady with a soft tone and volume. His thought process s congruent and future-oriented. His judgment and insight are intact. He has no hallucinations, paranoid behavior, and suicidal ideation.
Diagnostics tests
- Total serum IgE helps rule out allergic rhinitis
- Allergy skin test
- Total blood eosinophil count supports the diagnosis of allergic rhinitis when it is high
- A 3-view sinus series radiograph evaluates sinusitis and adenoid hypertrophy
- Coronal CT scan imaging evaluates acute and chronic sinusitis (these are complications of rhinitis).
Assessment
The patient presents with cough, running nose, fatigue, pain in the right ear, and throat soreness. He is allergic to fur, cold air, dust, and pollen. He has a positive family history of asthma. Upon examination, the patient has moist mucus membranes, clear nasal discharge, redness of the throat, dull eyes with pink conjunctiva, right cervical lymph node, and inflamed right tympanic membrane. The most probable diagnoses are allergic rhinitis, common cold, and Strep throat.
Differential diagnoses
Allergic rhinitis is the inflammation of the nasal membranes characterized by sneezing, coughing, itching ears, nose, and eyes, congestion, postnasal drip, fatigue, drowsiness, and rhinorrhea (Zhang, et al, 2021). The prevalence of allergic rhinitis is 7% in younger children less than 18years old. The patient has allergic rhinitis because the trigger is cold air at night in addition, he presents with sleep disturbance due to worsening cough at night. He has otitis media, conjunctivitis, fatigue, palatal abnormalities, and thin watery nasal secretions.
The common cold is an upper respiratory tract infection caused by rhinoviruses. It presents with a sore throat, nasal discharge, congestion, coughing, low-grade fever, hoarseness of the voice, and running nose (Czubak, et al, 2021). Its transmission occurs when there is close exposure to infected respiratory secretions, through the nose, mouth, eyes, and skin. It is more prevalent in school-going children. However, this is not the actual diagnosis because the patient has moist mucus membranes, clear nasal discharge, redness of the throat, dull eyes with pink conjunctiva, right cervical lymph node, and inflamed right tympanic membrane. In common cold, the patient presents with non-tender cervical lymph nodes and rhonchi upon auscultation. There is no obvious erythema edema of the airway.
Strep throat is the inflammation of the throat and the tonsil caused by group A streptococcus. Clinical presentations of strep throat are fever, red swollen tonsils, throat pain, cervical lymph nodes, headache, abdominal pain, malaise, and headache (Alkahlout, et al, 2021). A viral throat infection presents with coughing, running nose, hoarse voice, and conjunctivitis. This is not the actual diagnosis because the patient denies fever, white patches on the throat, and abdominal pain.
References
Alkahlout, M. A., Abujamie, T. N., & Abu-Naser, S. S. (2021). Throat Problems Expert System Using SL5. International Journal of Academic Information Systems Research (IJAISR), 5(5).
Czubak, J., Stolarczyk, K., Orzeł, A., Frączek, M., & Zatoński, T. (2021). Comparison of the clinical differences between COVID-19, SARS, influenza, and the common cold: A systematic literature review. Advances in Clinical and Experimental Medicine, 30(1), 109-114.
Zhang, Y., Lan, F., & Zhang, L. (2021). Advances and highlights in allergic rhinitis. Allergy, 76(11), 3383-3389.
Sample Answer 2 for NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
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
Sample Answer 3 for NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
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.
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
Sample Answer 4 for NURS 6512 Assignment 2: Digital Clinical Experience: Focused Exam: Cough
SUBJECTIVE DATA:
Chief Complaint (CC): Abuela brought him in because he has been feeling sick and coughing a lot and feel kind of tired.”
History of Present Illness (HPI): Danny reports a cough lasting four to five days. He describe the cough as ” watery and gurgly” He reports being feeling tired because the cough is worse at night and keeps him up. He reports pain in his right ear and mild soreness in his throat. He reports his mother treated his cough symptoms with over the counter cough medication that was temporarily effective. He reports frequent cold and runny nose. Patient has had no exposure to sick individuals. Patient denies having allergies
Medications: Pt. denies daily prescriptions. He takes a daily OTC multivitamin. Today his mother gave him a cough medication that temporarily relieved the symptoms he was experiencing.
Allergies:
Past Medical History (PMH): Frequent ear infections as small child. Patient reports last known ear infection was when he was two years old. He reports having pneumonia last that caused him to miss two weeks of school
Past Surgical History (PSH): No surgical history
Sexual/Reproductive History: Not sexually active.
Personal/Social History: In the third grade Out for two weeks last year because of pneumonia Live with Mother, Father, grandmother, grandmother cares for child while parents are working Primarily speaks English in the house but sometimes Spanish
Immunization History: Rivera’s immunization record is up to date.
Significant Family History: Mother: type 2 diabetes, hypertension, hypercholesterolemia, spinal stenosis, obesity Father: smoker, hypertension, hypercholesterolemia, Asthma as a child Maternal grandmother: type 2 diabetes and hypertension Maternal grandfather: smoker, eczema. Paternal grandmother: died at age 52 of a car accident Paternal grandfather: no known history
Review of Systems:
General: Denies fever, denies chills, denies weigh loss or gain, denies night sweats. Reports feeling “kind of tired”.
HEENT: Mucus membranes are moist, nasal discharge, and boggy turbinate. Fine bumps on the togue. Cobblestoning in the back of throat. Eyes are dull in appearance, pink Conjunctiva. Cardiovascular: Mild tachycardia. S1, S2, no murmurs, gallops or rubs. Right Tympanic membrane is red and inflamed.
Respiratory: Respiratory rate increased, but no acute distress. Able to speak full sentences. Breath sounds clear to auscultation. Chest wall resonant to percussion
Cardiovascular/Peripheral Vascular: Mild tachycardia. S1, S2, no murmurs
Psychiatric: No history of mental illness
Neurological: No neurological deficit noted, patient was alert and oriented to time and place.
Lymphatics: Right cervical lymph node enlarged with reported tenderness.
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Blood Pressure: 120/76, O2 Sat 96, Pulse 100, Resp. Rate 28 Temp 37.2 Ht. 50 inches, Wt. 68 lbs., BMI: 19.1
General: Patient appeared very healthy, well oriented to time and place.
HEENT: The sclera white, conjunctiva moist and pink bilaterally. Rhinorrhea with clear mucus, nasal mucosa is boggy bilaterally. Right tympanic membrane is erythematous with inflammation. Right cervical lymph node is enlarged with noted tenderness. oral mucosa moist and pink. Tonsils 2+ with erythema and inflammation. Posterior pharynx is erythematous with cobblestoning. Fine bumps noted on tongue.
Respiratory: Chest is symmetrical with respirations. Increased respiratory rate. Audible coarse crackles in upper airway; bronchovesicular bilaterally, clears with cough. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FVC = 1.78L FEV1 = 1.549L FEV1/FVC: 87%
Cardiology: Mild tachycardia noted, no gallops, murmurs noted. S1 and s2 heart sounds are present and regular.
Lymphatics: Palpable cervical nodes on the right side, not on the left. No palpable nodes
in the axillary region. No palpable nodes in the supraclavicular region. No tenderness or
pain in the examination.
Psychiatric: No psychiatric history
Diagnostics/Labs: Chest X-Ray to rule of pneumonia, Covid swab to rule out Covid
ASSESSMENT:
Upper respiratory infection: URI common include symptoms of cough, sore throat, and runny
nose, which is sufficiently diagnosed through assessment of these common symptoms, especially
when more serious respiratory illness is absent such as color phlegm, difficulty breathing, fever,
or chest congestion (Thomas & Bomar, 2020).
Differential diagnoses:
Pharyngitis: Upper respiratory infections often involve the pharynx and cause irritation and
inflammation in the pharynx (Thomas & Bomar, 2020). This is a possible differential diagnosis
due to the slight sore throat and redness, and cobblestoning noted on assessment.
Allergic rhinitis: The reports of cough and runny nose with clear sputum coupled with red
cobblestoning throat, an abnormal assessment finding when polygonal cells protrude from
mucosal surfaces, could indicate allergic rhinitis due to various allergens. (La Mantia &
Andaloro, 2017)
Covid: In the current state of the Covid pandemic, testing for Covid in light of minimal
symptoms may be prudent to prevent the spread of the illness. While Covid cases report a wide
range of clinical symptoms, including cough, runny nose, and sore throat, they are often reported
and common even in the absence of lung congestion, fever, or discomfort (Arashiro et al., 2020).
References
Arashiro, T., Furukawa, K., & Nakamura, A. (2020). COVID-19 in 2 persons with mild upper
respiratory tract symptoms on a cruise ship, Japan. Emerging Infectious Diseases, 26(6),
1345–1348. https://doi.org/10.3201/eid2606.200452
La Mantia, I., & Andaloro, C. (2017). Cobblestone appearance of the nasopharyngeal mucosa.
The Eurasian Journal of Medicine, 49(3), 220–221.
https://doi.org/10.5152/eurasianjmed.2017.17257
Thomas, M., & Bomar, P. (2020, October 28). Upper respiratory tract infection. StatPearls
[Internet]. https://www.ncbi.nlm.nih.gov/books/NBK532961/
Also Read:
NURS 6512 Assignment 1: Lab Assignment: Assessing the Abdomen
NURS 6512 Discussion Musculoskeletal Pain
NURS 6512 Assignment 1: Case Study Assignment: Assessing Neurological Symptoms
NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
NURS 6512 Assignment Assessing The Genitalia And Rectum
NURS 6512 Assignment Ethical Concerns
NURS 6512 Week 9 Assessment Of Cognition And The Neurologic System
NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children
NURS 6512 Assignment 1: Lab Assignment: Assessing the Genitalia and Rectum
Discussion: NURS 6512 Assessing the Ears, Nose, and Throat
Discussion: NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children
Discussion: NURS 6512 Effective Communication
Assignment: NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children
NURS 6512 The Ethics Behind Assessment
NURS 6512 Cognition and the Neurologic System
NURS 6512 Assessment of the Musculoskeletal System
NURS 6512 Assignment Cardiovascular Disease (CVD)
NURS 6512 Abdomen and Gastrointestinal System
NURS 6512 Functional, Cultural and Diversity Awareness in Health
NURS 6512 Building a Comprehensive Health History
NURS 6512 TJ Pregnant Lesbian Essay
NURS 6512 Health History of Tina Jones
NURS 6512 Discussion Week 1 Main Post
NURS 6512 Assignment 2 Focused Exam
NURS 6512 Practice Assessment Skin, Hair, and Nails Examination
NURS 6512 Digital Clinical Experience
NURS 6512 Tools and Diagnostic Tests in Adults and Children
NURS 6512 Episodic/Focused SOAP Note Template
NURS 6512 Discussion Episodic/Focused SOAP Note
NURS 6512 Discussion Adolescent Patients
NURS 6512 Effective communication is required needed in any patient-healthcare provider interaction
NURS 6512 Primary care is a critical aspect of patient care
NURS 6512 Cultural beliefs played a key role in patient health
NURS 6512 Research the health-illness continuum and its relevance to patient care
NURS 6512 discuss the relevance of the continuum to patient care
NURS 6512 Cultural and linguistic competence
NURS 6512 Health assessment of the skin, hair and nails
NURS 6512 The abdomen and the gastrointestinal system Assignment
NURS 6512 Congestive Heart Failure
NURS 6512 Acute Lateral Ankle Sprain
NURS 6512 Bilateral Ankle Pain
NURS 6512 Discussion Categories to Differentiate Knee Pain
NURS 6512 Assessing The Neurologic System
NURS 6512 Comprehensive Physical Assessment
NURS 6512 ethical dilemmas Assessment
NURS 6512 History of Present Illness (HPI)
NURS 6512 provision of quality and effective healthcare services to the diverse population