Cough Diagnosis Reflective Question Sample PaperSituation In Danny’s case, I applied the SOAP mode

Cough Diagnosis Reflective Question Sample Paper

Situation

In Danny’s case, I applied the SOAP model to interview him and his grandmother during his clinical check-up visit. Unclear answers were referred to Danny’s grandmother to verify, hence give a better understanding of the symptoms and history. I utilized the opportunity to educate the patient and his grandmother on aspects relevant to Danny’s cough such as his smoking grandfather. I utilized my clinical guidebook, notes and online resources to better understand the symptoms presented, and to rule out differential diagnoses. Past medical history of the patient and his family guided me in developing a diagnosis. I also performed a comprehensive assessment including physical examination and review of the body systems. Physical examination followed the inspection, palpation, percussion, and auscultation order as guided by my notes. The respiratory system was emphasised as guided by the cough diagnosis.

Feelings

The above shadow case felt less complicated as compared to previous case studies. I felt ready to handle the Danny’s case from assessment to planning for care. My confidence helped me settle on my established diagnosis, which came out correct. I felt comfortable performing the head-to-toe examination without referring to a secondary source as it was last time. Review of the systems was however confusing, especially differentiating the lung sounds. The results were encouraging, especially in the assessment and history taking sections, that are definitive of the final diagnosis. I feel more at ease with medical patient care and prepared to handle a clinical case during my practice. In general, the shadow case offered an excellent case study for me to sharpen my clinical skills as a nurse. Subsequent assessments will gradually boost my competence.

Clinical reasoning

Decision making on the final diagnosis was resolved after critical analysis of the patient’s symptoms and medical reports. Danny presented at the clinic with no shortness of breath, and his subjective history revealed no acute distress. This made it easier for me to conduct a subjective and objective assessment. The history report guided my decision and plan for management. Follow-up made to my clinical notes and online resources agreed with my established care plan. My decision narrowed down to the clinical diagnosis of upper respiratory infection, attributed by the recurrent coughs with clear sputum. The patient denied any allergies, fevers, headaches, or chest pains but reported mild pain when swallowing. I recommended management with broad-spectrum antibiotics, which have higher potential in management of upper respiratory infections. Antihistamines, although frequently used, have no evident therapeutic effect when compared to placebos (Sharma, Hashmi & Alhajjaj, 2020). Danny is likely to develop recurrent upper respiratory infections if exposed to smokers, especially in the same house.

Learning opportunities

From the assessment results and recommendations, I felt I did better this time as compared to previous ones. I realize I need to be quicker with my interviews, by making more problem-focussed questions and applying better communication skills. The exercise helped me realise the need to review patient’s chart before commencing an interview. Information from the chart can act as guide to the areas of focus during history taking. I could also better my competence by practising more as there is room for improvement. As a student nurse, I observe and seek advice from peers and clinical mentors on how to better these skills. I will use this practice and results as a basis for my competence enhancement plan before the next assessment.

Plan of care

For patients presenting with cough, it is ideal to indicate baseline investigations to avoid missed symptoms and misdiagnosis. A chest x-ray is commonly done to assess the anatomy of the chest cavity and to rule out pneumonia. Although they are normal in most cases, the film could indicate fluid or air outside the lungs as a critical symptom. Also performed is a complete blood count test to establish the presence of an infection in the body. Patients with upper respiratory infections are likely to have elevated white blood cells. This test, however, does not establish the specific causative agent which is necessary in directing the mode of antibiotic therapy (Amos, 2018). Specimen culture of the sputum conducted in the laboratory helps to identify the microorganism. Although this test is time-consuming, the results help clinicians administer an antibiotic specific to the causative agent, hence quick recovery.

Danny’s presenting symptoms are indicative of various possible diagnoses. His cough, with clear sputum could indicate asthma. Although asthma mostly presents with wheezing and difficult breathing, cough may be the only symptom. A complete blood count test done in asthmatic patients indicates elevated eusionophils (Ajay & Kamerman-Kretzmer, 2019). Cough could also be the result of gastro-oesophageal reflux disorder (GERD). GERD presents with frequent coughs due to sensation of a lump in the throat. This diagnosis however presents with heartburn that worsens with eating and night fall, a feature absent in Danny. Acute bronchitis is characterised by persistent cough, sore throat, nasal congestion and fever. Although a possible diagnosis, Danny’s does not present with sore throat and chest tenderness. A broad-spectrum antibiotic such as Amoxicillin would be ideal for coughs among paediatrics. In the case of Danny, I prescribed Robitussin 10ml PO taken every six hours or as needed. A non-steroidal anti-inflammatory drug such as ibuprofen is also recommended as an antipyretic and analgesic. Also included in the plan of care are health promotion and anticipatory guidance, which entail increased fluid intake for hydration, knowledge of worsening symptoms, such as shortness of breath, wheezing, etc.

References

• Kasi, A. S. & Kamerman-Kretzmer, R. J. (2019). Cough. Pediatrics in Review, 40(4), 157-167. DOI: 10.1542/pir.2018-0116
• Amos L. B. (2018). 2 – Cough. Nelson Pediatric Symptom-Based Diagnosis, 15–38. https://doi.org/10.1016/B978-0-323-39956-2.00002-9
• Sharma, S., Hashmi, M. F., & Alhajjaj, M. S. (2020). Cough. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493221/

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