Focused Exam-NR-509 Advanced Physical Assessment-Cough-Documentation.pdf

Daniel "Danny " Rivera, 8 year old male of Puerto Rican descent. CC" patience abuela brought him in because he has been feeling sick and coughing a lot and feel kind of tired." HPI: Cough onset 5 days ago, pt describe cough" gurgly and watery" . reports sputum color is clear. Reports coughing every few minutes and worse at night. Patient denies smoking but exposed to secondhand smoke in the house through father and grandfather. Reports does not know what makes his cough worse. Alleviating factors of the cough is some cough medicine in the morning. Reports having cough medicine everything for the past 5 days, describes it as purplish in color one spoon full 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 daysDanny 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