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NR 509-Shadow Health Focused Exam- Cough documentation
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6/4/2018 Focused Exam: Cough | Completed | Shadow HealthFocused Exam: Cough Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment
Your Results Lab Pass
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Overview
Documentation / Electronic Health Record
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Transcript
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Subjective Data Collection Document: Vitals Document: Provider Notes
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Objective Data Collection
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Education & Empathy Document: Provider Notes
Documentation
Student Documentation Model Documentation
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Self-Reflection
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Subjective
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Danny reports a cough lasting four to five days. He
Daniel "Danny " Rivera, 8 year old male of Puerto describes the cough as “watery and gurgly.” He
Rican descent. reports the cough is worse at night and keeps him
CC" patience abuela brought him in because he has up. He reports general fatigue due to lack of sleep.
been feeling sick and coughing a lot and feel kind of He reports pain in his right ear. He is experiencing
ed d
tired." mild soreness in his throat. He reports his mother
HPI: Cough onset 5 days ago, pt describe cough" treated his cough symptoms with over-the-counter
ar stu
gurgly and watery" . reports sputum color is clear. medicine, but it was only temporarily effective. He
Reports coughing every few minutes and worse at reports frequent cold and runny nose, and he states
night. Patient denies smoking but exposed to that he had frequent ear infections as a child. He
secondhand smoke in the house through father and reports a history of pneumonia in the past year. He
sh is
grandfather. Reports does not know what makes his reports normal bowel movements. He denies fever,
cough worse. Alleviating factors of the cough is headache, dizziness, trouble swallowing,
Th
some cough medicine in the morning. Reports nosebleed, phlegm or sputum, chest pain, trouble
having cough medicine everything for the past 5 breathing and abdominal pain. He denies cough
days, describes it as purplish in color one spoon full aggravation with activity.
and giving my mom. Has physical exercise everyday
still able to run around and play and cough not
making it difficult to play gets bored with easy
school work. Reports currently having a runny nose
and frequent rhinorrhea denies any sneezing.
Reports nasal drainage clear and watery also thin.
Reports a 3/10 in Right ear. Denies any pain to the
left ear. Patient reports history of frequent ear
infections around 2 years of age.
Can I use any ear drainage or hearing problems.
Had hearing test at school approximately about a
month ago.
Current Medication: Multi vitamin every day "
gummy dinosaur", cough med for the past 5 days
https://www.coursehero.com/file/31530124/Focused-Exam-Cough-documentation-pdf/
https://chamberlain.shadowhealth.com/assignment_attempts/3552952 1/4
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