NURS 6512N: Updated Advanced Health Assessment & Diagnostic Reasoning Episodic/Focused Note for Focused Exam: Cough

NURS 6512N: Updated Advanced Health Assessment & Diagnostic Reasoning Episodic/Focused Note for Focused Exam: Cough Patient Name: Daniel Rivera Age: 8 Gender: Male SUBJECTIVE DATA: Chief Complaint (CC): " I have been coughing a lot." History of Present Illness (HPI): Danny is a 8-years-old-boy. He states coughing started 5 daysago. Coughs with clear sputum. Reports sore throat and running nose with clear, thin discharge.Reports right ear hurting since yesterday, rated as 3/10 on the pain scale. Denies fever. Mom gives coughing medicine to relieve the symptom. Reports feeling tired at times. Sleep disturbances by overnight coughing. Denies breathing problem or asthma. Current Medications: 1. OTC cough medicine (name unknown). one spoon given. 2. Daily multivitamin (Gummy Bears – name unknown) Allergies: • Denies any food allergy. • Denies any medication allergy. • Denies seasonal allergy. • Denies allergic to any animals.