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.

Digital clinical experience: focused exam: cough | NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology | Walden University

Introduction:

In this focused exam assignment, the patient presents with cough symptoms. The objective is to collect the patient’s history, conduct physical exams and diagnostic tests, and formulate a differential diagnosis with several possible conditions.

Patient Information:

The patient is a 28-year-old female who presents with a cough that has been ongoing for the past four days. The patient reports that the cough is productive, with yellowish sputum, and she is experiencing chest discomfort while coughing. She denies any shortness of breath, wheezing, fever, chills, or night sweats.

History:

The patient’s history should include questions about the onset of the cough, duration, frequency, and intensity of the cough, presence of any associated symptoms such as fever, chills, night sweats, chest pain, or shortness of breath. The patient’s medical history, allergies, and medication use should also be collected.

Physical Exam:

Physical exams that should be conducted include inspection, auscultation, palpation, and percussion of the chest. The patient’s vital signs should also be obtained, including respiratory rate, heart rate, blood pressure, and oxygen saturation.

Diagnostic Tests:

Based on the patient’s symptoms and physical exam findings, several diagnostic tests may be appropriate, including a chest x-ray, sputum culture and sensitivity, complete blood count, and pulmonary function tests. These tests can help to identify possible causes of the cough, such as pneumonia, bronchitis, asthma, or chronic obstructive pulmonary disease (COPD).

Differential Diagnosis:

Possible differential diagnoses for the patient’s cough symptoms include acute bronchitis, pneumonia, asthma, and COPD. Other potential causes of cough include allergies, gastroesophageal reflux disease (GERD), and upper respiratory infections.

Treatment:

The treatment plan will depend on the underlying cause of the cough. For acute bronchitis or pneumonia, antibiotics may be prescribed. For asthma or COPD, bronchodilators or corticosteroids may be prescribed. If the cough is caused by GERD, medications to reduce acid reflux may be recommended.

Conclusion:

In conclusion, conducting a focused exam for a patient with cough symptoms involves collecting a comprehensive history, conducting physical exams, and performing appropriate diagnostic tests. The information gathered will help to formulate a differential diagnosis and determine an appropriate treatment plan for the patient.