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Digital Clinical Experience Cough Discussion Assignment

Digital Clinical Experience Cough Discussion AssignmentDigital Clinical Experience Cough Discussion AssignmentAssignment 2: Digital Clinical Experience: Focused Exam: CoughIn this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.ASSIGNMENT INSTRUCTIONS:· Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough use this template to complete your Documentation Notes for this DCE Assignment.· Please review the transcripts and data with information to complete the 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?Digital Clinical Experience Cough Discussion AssignmentORDER A PLAGIARISM-FREE PAPER HERE· APA 7· Use at least 5 referencesAssignment 2: Digital Clinical Experience: Focused Exam:CoughIn this DCE Assignment, you will conduct a focused exam related to cough inyour DCE using the simulation tool, Shadow Health. You will determine whathistory should be collected from the patient, what physical exams anddiagnostictests should be conducted, and formulate a differential diagnosis with severalpossible conditions.  ASSIGNMENT INSTRUCTIONS:  ·Digital Clinical Experience Cough Discussion Assignment Review the DCE (Shadow Health) Documentation Template for Focused Exam:Coughuse this template to complete your Documentation Notes for this DCEAssignment. · Please review thetranscripts and data with information to completethe assignment. · Consider what physical exams and diagnostic tests would be appropriate togather more information about the patient’s condition. How would the results beused to make a diagnosis? ·Digital Clinical Experience Cough Discussion AssignmentAPA 7 · Use at least 5 references     Assignment 2: Digital Clinical Experience: Focused Exam:Cough In this DCE Assignment, you will conduct a focused exam related to cough inyour DCE using the simulation tool, Shadow Health. You will determine whathistory should be collected from the patient, what physical exams and diagnostictests should be conducted, and formulate a differential diagnosis with severalpossible conditions. ASSIGNMENT INSTRUCTIONS:  Review the DCE (Shadow Health) Documentation Template for Focused Exam:Cough use this template to complete your Documentation Notes for this DCEAssignment. Please review the transcripts and data with information to complete theassignment. Consider what physical exams and diagnostic tests would be appropriate togather more information about the patient’s condition. How would the results beused to make a diagnosis?Digital Clinical Experience Cough Discussion Assignment APA 7 Use at least 5 referencesInstructions:1. Review the complete instructions and the grading rubric.2. Use the provided template to complete the assignment ( Word Document)3. Review the attached transcripts and data to complete the assignment. ( PDF’s documents and word document)4. APA 75. Use at least 5 references.Established chief complaintReports coughDigital Clinical Experience Cough Discussion AssignmentAsked about onset of coughReports cough started 3 days ago Asked about characteristics of coughReports cough is wet Reports clear sputum with cough Asked about frequency and duration of coughReports coughing every few minutes Reports coughs last a few seconds Asked about aggravating factors for coughReports cough is worse at night Denies smoking Reports being exposed to secondhand smoke through father Reports he doesn’t know what triggers the cough Asked about exposure to germsReports playing with an ill classmate Asked about hand hygieneReports infrequent hand washing Reports occasionally putting fingers in eyes, nose, or mouth Asked about cough etiquetteDenies covering mouth when coughing Asked about relieving factors for coughReports cough is temporarily relieved by cough medicineFollowed up on cough medicineReports cough medicine was purple Reports taking one spoonful of cough medicine Reports mother gave him the medicine Reports only took the medicine this morning Denies home remediesName:Section:Digital Clinical Experience Cough Discussion AssignmentWeek 5Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation SUBJECTIVE DATA: Include what the patient tells you but organize the information. Chief Complaint (CC):History of Present Illness (HPI):Medications:Allergies:Past Medical History (PMH):Past Surgical History (PSH):Sexual/Reproductive History:Personal/Social History:Immunization History:Significant Family History (Include history of parents, Grandparents, siblings, and children): Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.HEENT:Respiratory:Cardiovascular/Peripheral Vascular:Digital Clinical Experience Cough Discussion AssignmentPsychiatric:Neurological:Lymphatics: 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: Include vital signs, ht, wt, temperature, and BMI and pulse oximetryGeneral: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.HEENT:Respiratory: Always include this in your PE.Cardiology: Always include the heart in your PE.Lymphatics:Psychiatric: Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.Digital Clinical Experience Cough Discussion Assignment    © 2021 Walden University  © 2021 Walden University  Name: Section:  Week 5 Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation  SUBJECTIVE DATA:Include what the patient tellsyou but organize the information.  Chief Complaint (CC):Digital Clinical Experience Cough Discussion AssignmentHistory of Present Illness(HPI): Medications: Allergies: Past Medical History (PMH): Past Surgical History (PSH): Sexual/Reproductive History: Personal/Social History: Immunization History: Significant Family History (Include history of parents, Grandparents, siblings, and children):  Review of Systems:From head–to–toe, include each system that covers the Chief Complaint,History of Present Illness, and History). Remember that the information you include in thissection is based on what the patient tells you.You will only need to cover systems pertinent toyour CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). Digital Clinical Experience Cough Discussion AssignmentGeneral:Include any recent weight changes, weakness, fatigue, or fever, butdo notrestate HPI data here.  HEENT:  Respiratory:  Cardiovascular/Peripheral Vascular:    © 2021 Walden University Name:Section: Week 5Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation SUBJECTIVE DATA: Include what the patient tells you but organize the information.Digital Clinical Experience Cough Discussion AssignmentChief Complaint (CC):History of Present Illness (HPI):Medications:Allergies:Past Medical History (PMH):Past Surgical History (PSH):Sexual/Reproductive History:Personal/Social History:Immunization History:Significant Family History (Include history of parents, Grandparents, siblings, and children): Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,History of Present Illness, and History). Remember that the information you include in thissection is based on what the patient tells you. You will only need to cover systems pertinent toyour CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). General: Include any recent weight changes, weakness, fatigue, or fever, but do notrestate HPI data here.HEENT:Respiratory:Cardiovascular/Peripheral Vascular:10/2/21, 12:54 AM Rubric Detail – Blackboard Learnhttps://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559587_1 1/4Rubric Detail Select Grid View or List View to change the rubric’s layout.Excellent Good Fair PoorStudent DCE score(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)Note: DCE Score – Do not round up on the DCE score.56 (56%) – 60 (60%)Digital Clinical Experience Cough Discussion AssignmentDCE score>9351 (51%) – 55 (55%)DCE Score 86- 9246 (46%) – 50 (50%)DCE Score 80- 850 (0%) – 45 (45%) DCE Score <79No DCE completed.Name: NURS_6512_Week_5_DCE_Assignment_2_RubricDescription: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.EXITGrid View List View10/2/21, 12:54 AM Rubric Detail – Blackboard Learnhttps://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559587_1 2/4Digital Clinical Experience Cough Discussion AssignmentExcellent Good Fair PoorSubjective Documentation in Provider NotesSubjective narrative documentation in Provider Notes is detailed and organized and includes:Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of di�erential diagnoses. You should list each system as follows: General: Head: EENT: etc.You should list these in bullet format and document the systems in order from head to toe.16 (16%) – 20 (20%)Documentation is detailed and organized with all pertinent information noted in professional language.Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).11 (11%) – 15 (15%)Documentation with su�cient details, some organization and some pertinent information noted in professional language.Digital Clinical Experience Cough Discussion AssignmentDocumentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).6 (6%) – 10 (10%) Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).0 (0%) – 5 (5%) Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).Digital Clinical Experience Cough Discussion AssignmentorNo documentation provided.10/2/21, 12:54 AM Rubric Detail – Blackboard Learnhttps://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559587_1 3/4Excellent Good Fair PoorObjective Documentation in Provider Notes – this is to be completed in Shadow HealthPhysical exam: Document in a systematic order starting from head- to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam �ndings. Do not use “WNL” or “normal”.Digital Clinical Experience Cough Discussion AssignmentYou only need to examine the systems that are pertinent to the CC, HPI, and History.Diagnostic result – Include any pertinent labs, x- rays, or diagnostic test that would be appropriate to support the di�erential diagnoses mentionedDi�erential Diagnoses (list a minimum of 3 di�erential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).16 (16%) – 20 (20%)Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.Each system assessed is clearly documented with measurable details of the exam.11 (11%) – 15 (15%)Documentation with su�cient details and some organization; some abnormal and some normal assessment information described in mostly professional language.Digital Clinical Experience Cough Discussion AssignmentEach system assessed is somewhat clearly documented with measurable details of the exam.6 (6%) – 10 (10%) Documentation with inadequate details and/or organization; inadequate identi�cation of abnormal and pertinent normal assessment information described; inadequate use of professional language.Each system assessed is minimally or is not clearly documented with measurable details of the exam.0 (0%) – 5 (5%) Documentation with no details and/or organization; no identi�cation of abnormal and pertinent normal assessment information described; no use of professional language.None of the systems are assessed, no documentation of details of the exam.orNo documentation provided.Digital Clinical Experience Cough Discussion AssignmentTotal Points: 10010/2/21, 12:54 AM Rubric Detail – Blackboard Learnhttps://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559587_1 4/4Name: NURS_6512_Week_5_DCE_Assignment_2_RubricDescription: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.Digital Clinical Experience Cough Discussion AssignmentFocused Exam: Cough Results | Turned In Advanced Health Assessment – Chamberlain, NR509-August-2018Return to AssignmentYour Results Lab Pass Lab PassThis score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.Digital Clinical Experience Cough Discussion AssignmentPatient: Danny RiveraDigital Clinical Experience Score100%Beginning Developing ProficientSubjective Data Collection 20 out of 20Objective Data Collection 12.8 out of 13Education and Empathy 3 out of 5Interaction with patient 287 minutesPost-exam activities 22 minutesTime 309 minutes total spent in assignmentStudent Performance Index 35.8 out of 38Proficiency Level: ProficientStudents rated as “proficient” demonstrate an entry- level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.Document: Vitals Document: Provider NotesDocument: Provider NotesOverviewTranscriptSubjective Data CollectionObjective Data CollectionEducation & EmpathyDocumentationSelf-ReflectionExperience OverviewDocumentation / Electronic Health RecordThis study source was downloaded by 100000829165196 from CourseHero.com on 10-01-2021 19:56:56 GMT -05:00Digital Clinical Experience Cough Discussion Assignmenthttps://www.coursehero.com/file/35109206/Coughpdf/Th isstu dyre sour cew assh ared viaCo urse Her o.co m https://www.coursehero.com/file/35109206/Coughpdf/ Student DocumentationStudent Documentation Model DocumentationModel DocumentationSubjectiveCC: CoughHPI Onset: 4-5 days agoLocation: right ear painDuration: “a couple of minutes”Characteristics: sore throat (mild), fatigueAggravating factors: night timeRelieving factors: cough syrupTreatment: OTC cough syrupCurrent medications: multivitamins and cough syrupAllergies: nonePMHx: pneumonia, frequent ear infections during early childhoodSocial Hx: The patient lives with his mother, father, and maternal grandmother and grandfather. Father sometimes smoke in the house.Digital Clinical Experience Cough Discussion AssignmentFamily Hx: Father had asthma as a child and is a current positive smoker. Maternal grandfather also has a smoking history and diagnosed with eczema.ROS Constitutional: Positive for fatigue related to cough that keeps him up at night. Denies night sweats, fevers, chills, and weight loss.HEENT: Denies headaches and dizziness. Denies nosebleeds. Positive for right ear pain. Denies ear drainage. Positive for clear nasal discharge. Denies eye redness, watery eyes, eye pain and visual disturbances. Positive for sore throat.Cardiac: Denies chest pain and tightnessResp: Positive for dry cough. Denies shortness of breath.GI: Denies nausea, vomiting, diarrhea. Denies abdominal pain and discomfort. Last BM was today before school.Danny reports a cough lasting four to five days. He describes the cough as “watery and gurgly.” He reports the cough is worse at night and keeps him up. He reports general fatigue due to lack of sleep. He reports pain in his right ear. He is experiencing mild soreness in his throat. He reports his mother treated his cough symptoms with over-the-counter medicine, but it was only temporarily effective. He reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, trouble swallowing, nosebleed, phlegm or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity.Digital Clinical Experience Cough Discussion AssignmentObjectiveDanny Rivera is an 8 year old Puerto Rican male who presents to the clinic with a cough. He is alert and oriented to person, place, time and situation. He is answering questions appropriately. He is in no acute distress.• General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable.This study source was downloaded by 100000829165196 from CourseHero.com on 10-01-2021 19:56:56 GMT -05:00https://www.coursehero.com/file/35109206/Coughpdf/Th isstu dyre sour cew assh ared viaCo urse Her o.co mDigital Clinical Experience Cough Discussion Assignmenthttps://www.coursehero.com/file/35109206/Coughpdf/ HEENT: Head is normocephalic and atraumatic. Sclera white, conjunctive moist and pink with no drainage. Right ear positive for pain. Inflammation and redness noted in right tympanic membrane. Nasal cavities pink, patent with clear drainage. Negative for tenderness on palpation at frontal and maxillary sinuses. Oral mucosa moist and pink. Erythema noted to tonsils. Posterior throat is red with cobblestoning. Right sided cervical lymph nodes are tender on palpation.Resp: Lung sounds are present and clear on auscultation in all lobes. Positive dry cough. Positive tachypnea. Negative for bronchophony. Chest wall is symmetrical and resonant in all areas on percussion. No areas of dullness noted. Fremitus symmetrical and equal bilaterally on palpation. Spirometry result: FEV1/FEVC 80.5%Cardio: S1 and S2 heart sounds on auscultation. No murmurs, rubs, or gallops detected.Digital Clinical Experience Cough Discussion Assignment• HEENT: Mucus membranes are moist, clear nasal discharge. Redness, cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva. Right Tympanic membrane is red and inflamed. Right cervical lymph node enlarged with reported tenderness.• Cardiovascular: S1, S2, no murmurs, gallops or rubs.• Respiratory: Respiratory rate increased, but no acute distress. Able to speak in full sentences. Breath sounds clear to auscultation. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%)AssessmentCough/Viral rhinitis- dry cough for 4-5 days, sore throatStrep throat- throat redness, tenderness, and cobblestoningViral respiratory infection- clear nasal discharge and dry coughAsthma- cough, fatigue, frequent exposure to cigarette smoke.Allergies: clear nasal drainageCough. Differential diagnoses include cold, strep throat, rhinitis, allergies, and asthmaPlanDiagnostics: Order rapid strep test to rule out strep throat. Order sputum culture to rule out an respiratory infection. Consider ordering WBC and PFTs to help rule out asthma.Digital Clinical Experience Cough Discussion AssignmentMedication: Order antibiotics if rapid strep test is positive. Order robutussin DM 5mL every 6 hours PRN for cough for five days, do not administer more than 40mL a day. Order claritin (chewable tabs) 5mg twice daily for five days.Education: Educate patient to increase fluids. Educate patient to wash his hands frequently, demonstrate appropriate technique and assess return demonstration. Educate patient’s mother to wash bed linen weekly. Educate patient to avoid areas of smoke exposure. Educate and emphasize to the adult family members on the importance of not smoking in the house or in any area that the child will likely experience exposure. Educate parents to seek immediate medical attention for a fever >101.5, chest pain or tightness, shortness of breath, and dizziness.Diagnostics • Implement Centor criteria assessment • Obtain rapid strep testMedication • Pending rapid strep test results, may order appropriate antibiotic therapy • Initiate Rx or OTC antitussive therapy at bedtime for 10 daysEducation • Educate caregiver and patient to minimize exposure to allergens, practice good hand washing, and recommend cleaning bed sheets weekly • Request no smoking in houseReferral/Consultation • Refer to allergy specialist for allergy testing • Refer for lung function testing to rule out asthmaFollow-up Planning • Instruct caregiver and patient to seek immediateThis study source was downloaded by 100000829165196 from CourseHero.com on 10-01-2021 19:56:56 GMT -05:00Digital Clinical Experience Cough Discussion Assignmenthttps://www.coursehero.com/file/35109206/Coughpdf/Th isstu dyre sour cew assh ared viaCo urse Her o.co m https://www.coursehero.com/file/35109206/Coughpdf/ Referral/Consultation: Refer patient to ENT specialist for allergy testing. Refer patient to an pulmonologist or asthma specialist to rule out asthma.Follow-up: Have family bring patient back to the clinic in 7-10 days for follow-up.medical attention if high fever, shortness of breath, chest pain, and dizziness or faintness • Revisit clinic in 1-2 weeks for follow up and evaluationCommentsIf your instructor provides individual feedback on this assignment, it will appear here.Digital Clinical Experience Cough Discussion AssignmentThis study source was downloaded by 100000829165196 from CourseHero.com on 10-01-2021 19:56:56 GMT -05:00Digital Clinical Experience Cough Discussion Assignmenthttps://www.coursehero.com/file/35109206/Coughpdf/Th isstu dyre sour cew assh ared viaCo urse Her o.co mPowered by TCPDF (www.tcpdf.org)http://www.tcpdf.orgDigital Clinical Experience Cough Discussion Assignment

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