Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

Chief Complaint (CC): The patient presents to the clinic complaining of a productive cough with “slimy, clear” sputum.

History of Present Illness (HPI): The patient was well until 5 days ago when he started experiencing a sore throat that presented as throat irritation, an itchy feeling in the throat, and pain that increases when he swallows and also has swallowing difficulties.

On a scale of one to ten, his pain rating scale was two out of 10. He presents with a persistent cough that does not respond to hydration. He has not been in contact with anyone who has had any symptoms of the common cold. He does not have elevated temperature or pain in his muscles. The patient, however, complains about rhinorrhea that produces a clear watery discharge coupled with soreness in the throat with a pain scale of two out of ten.

Another major complaint is severe coughing that produces sputum, which makes him sleepless and uncomfortable at night. Rican also has ear pain in his right ear. He has used over-the-counter medications to control his cough, to be exact, a cough syrup that his mother gave him, but unfortunately, it only helped him for a short time before the symptoms came back.

Medications:  supplements of multivitamin and a purple antitussive

Allergies: no known allergies to any medications and drugs

Past Medical History (PMH):  recurrent otitis infections as a toddler, with the last treated symptomatology of otitis being treated when he was 2 years old. When he was 6 years old in 2020, he suffered from acute pneumonia and was treated at an emergency unit clinic.

Past Surgical History (PSH): the patient has never undergone surgeries or hospitalizations since birth.

Sexual/Reproductive History: The client has no sexual or reproductive history as he is only 8 years old.

Personal/Social History:  the patient is a third grader living with both parents who have full-time employment and is babysat by his grandmother when not at school. In 2020, when he was down with pneumonia, he missed school for two weeks to recover. The patient’s first and primary language is English, even though he understands and speaks Spanish.

Immunization History:  the patient’s childhood vaccination is up-to-date, and has received all childhood vaccinations except the HPV vaccination that is administered at age 10. The patient has not received any flu vaccine in the past 12 months.

Significant Family History: there is a significant family history of chronic illnesses in both parents’ families.  A positive family history of diabetes as his maternal grandmother and mother do have diabetes, and this increases his chances of becoming diabetic. Both parents suffer from hypertension, as well as his maternal grandmother, and therefore he is 3 times more likely to suffer from HTN. Both parents have hypercholesteremia, which predisposes them to HTN and possible cardiovascular illnesses. Paternal grandmother is deceased from a car accident at age 52.

Review of Systems:

General: has appropriate weight, is active, has no elevated temperatures, tiredness, or is sickly-looking. The patient is active and does the normal play activities of an 8-year-old boy.  The patient is breathing well and does not have any signs of respiratory distress. There are episodes of unproductive dry coughs every few minutes.

HEENT: right ear pain is reported by the patient and sore throat. Rhinorrhea is also reported by the patient. No further complaints in eyes and left ear

Respiratory: patient coughs and produces clear sputum.

Cardiovascular/Peripheral Vascular: the patient has never experienced arrhythmias, palpitations, or episodes of feeling faint or breathlessness.

Psychiatric: the patient is well oriented to time and place as well as he does not remember any episodes of retrograde or anterograde amnesia. No previous history of anxiety or depression.

Neurological: no history of seizures, head trauma, and twitches of extremities.

Lymphatics: no history of per orbital edema, peripheral edema, or central edema. No history of blood transfusion. Slight swelling of cervical lymphatic nodes.

Physical Exam (Jarvis et al., 2018):

Vital signs and General examination: the patient is a Mexican boy who is 8 years old with symmetrical facial and bodily features, no visible signs of disability or abnormal features like extra digits and double digits. The patient has a steady gait and a normal good posture.

The patient has a BMI of 19, weighs 24kgs, and has a height of 1.1 meters. Vital signs were taken: respirations-21 breaths per minute, BP 101/79 mmHg, pulse 79 beats per minute, and spO2 of 95%. The patient is tidy and well-dressed with well-kempt hair. No body odors and has a happy facial expression. The patient is conscious and aware of time and place. The patient is social and talks to everyone freely.  

Respiratory: The chest is symmetrical, and the shape of the chest is round. The rate, rhythm, and regularity of respiration is 21 respirations/min. The patient has rapid shallow breathing. There is bilateral chest movement. Apex beat and resonant heard in both lungs.

Cardiology: jugular venous pulsation in the neck, with the patient lying at a 30-40° angle below the clavicle. No thrills felt. S1 and s2 heart sounds were heard. No murmurs were heard.

Lymphatics: cervical lymph nodes are swollen.

Psychiatric: mental function is optimum, and the patient can add and subtract numbers.

Diagnostics/Labs: throat cultures, sputum culture, and examination

ASSESSMENT:  priority diagnosis is acute viral nasopharyngitis caused by rhinoviruses and influenza viruses. Moderate temperature, runny nose, nasopharyngeal congestion, nasopharyngeal secretion, bad breath, snorting, weeping, teary eyes, itchy throat, overall malaise, chills, and sometimes migraine and muscular pains are indicators and signs of viral rhinitis (Fedoseenko et al., 2021). Coughing frequently emerges as the disease advances. Viral rhinitis symptoms might continue for one to two weeks. The diagnosis is evident from the history of the symptoms and physical exams.

Acute rhinosinusitis is inflammation of the nasopharynx and paranasal sinuses. Acute rhinosinusitis can be bacterial or viral in nature. Acute rhinosinusitis frequently accompanies a viral upper respiratory infection or a worsening of allergic rhinitis (Saltagi et al., 2021). Nasal congestion induced by URI-related inflammation, edema, and fluid transudation causes sinus cavity blockage. This creates an ideal environment for bacterial development and therefore, nasal discharge.

Acute pharyngitis is a severe infection of the pharynx that arises abruptly. Viral pharyngitis spreads rapidly through aerosols of coughing and sneezing, as well as dirty hands subjected to infected fluids. Streptococcal pharyngitis causes a severe sore throat from one to five days following becoming infected with the streptococcus bacterium (Anderson et al., 2022).

Laryngitis is an acute inflammation of the larynx and is frequently caused by voice misuse, infection with toxicants, or as a result of a URI (Jaworek et al., 2018). Microbes that induce the flu and pharyngitis are also typical causes of laryngitis, and laryngitis is frequently accompanied by allergic rhinitis or pharyngitis. Acute laryngitis symptoms include loss of voice and a significant cough (Jaworek et al., 2018). The patient may appear with a persistent cough and a dry, painful throat, which worsens in the evening.

References

Anderson, J., Imran, S., Frost, H. R., Azzopardi, K. I., Jalali, S., Novakovic, B., Osowicki, J., Steer, A. C., Licciardi, P. V., & Pellicci, D. G. (2022). Immune signature of acute pharyngitis in a Streptococcus pyogenes human challenge trial. Nature Communications13(1), 769. https://doi.org/10.1038/s41467-022-28335-3

Fedoseenko, M., Fominykh, M., Makushina, E., Plenkovskaya, N., Kaliuzhnaia, T., Tolsrova, S., Selvyan, A., Privalova, T., & Shakhtakhtinskaya, F. (2021). 466 Clinical and epidemiological features of acute respiratory viral infections in children. Abstracts106, A195–A196.

Jarvis, C., Browne, A. J., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2018). Physical Examination and Health Assessment – Canadian E-book. Elsevier Health Sciences.

Jaworek, A. J., Earasi, K., Lyons, K. M., Daggumati, S., Hu, A., & Sataloff, R. T. (2018). Acute infectious laryngitis: A case series. Ear, Nose, & Throat Journal97(9), 306–313. https://doi.org/10.1177/014556131809700920

Saltagi, M. Z., Comer, B. T., Hughes, S., Ting, J. Y., & Higgins, T. S. (2021). Diagnostic criteria of recurrent acute rhinosinusitis: A systematic review. American Journal of Rhinology and Allergy35(3), 383–390. https://doi.org/10.1177/1945892420956871