lOMoARcPSD| 16290539
NR 602 Week 3 i Human Paisley Ward reason for
encounter Cough and shortness of breath Primary Care Of
The Childbearing and childrearing family (Chamberlain
University) nov 2025
NR 602 week 3 iHuman Paisley Ward 16y F
History of Present Illness
Reason for Encounter Cough and shortness of breath
History of present illness Patient presents with cough x 3 weeks following
URI sx of runny nose and congestion that
resolved after 1 week. Developed shortness of
breath 3 days ago. Cough is dry, nonproductive,
and worse at night. She denies any relieving
factors for the cough and has not tried any
treatments. Shortness of breath is worse at night
and with exertion. Episodes last about a minute
or so and are relieved by rest. She denies chest
pain but describes chest tightness.
Past Medical History
Past Medical History Well-controlled eczema with no flare-ups in a few
years. Reactive airway with more frequent
episodes when she was younger; untreated due
to self-resolution and limited family resources
Hospitalizations/Surgeries No previous hospitalizations or surgeries
Medications
Medications No prescription or OTC medications or
supplements
Allergies
Allergies NKDA
, lOMoARcPSD| 16290539
Preventive Health
Preventive Health Vaccinations are UTD
Family History
Family History Father: 42yo, eczema
Mother: 42yo, no medical problems
M.Grandmother: 84yo, hypertension
M. Grandfather: 82yo, gout, hyperlipidemia
Unknown paternal grandparent history
Social History
Social History Lives in an apartment with her parents. She is a
high school student. She does not drink alcohol,
use drugs, or use tobacco products. She is
exposed to secondhand smoke daily.
Review of Systems
General Denies fatigue, weight loss or gain, fever, or night
sweats. She reports cough is disrupting her sleep.
Integumentary/Breast Denies rashes, lesions, moles, or skin changes.
HEENT/Neck Denies headache, vision changes, ear pain, hearing
problems, sinus problems, sore throat, or difficulty
swallowing.
Cardiovascular Denies chest pain, dizziness, palpitations, or
blue/cold fingers or toes. Reports chest tightness.
Respiratory Reports dry, nonproductive cough and shortness
of breath. Denies wheezing
Gastrointestinal Denies nausea, vomiting, diarrhea, constipation, or
abdominal pain.
Genitourinary Denies frequency, urgency, dysuria, or hematuria
Musculoskeletal Denies muscle pain or weakness. Denies joint pain,
swelling, or redness.
Allergic/Immunologic Denies allergies
Endocrine Denies heat or cold intolerances, increased thirst,
increased sweating, frequent urination, or change
in appetite.
Hematologic/Lymphatic Denies bruising or bleeding.
Neurologic Denies dizziness, fainting, seizures, weakness,
numbness, or tingling.
Psychiatric Denies anxiety, mood changes, or hallucinations.
Physical Exams
NR 602 Week 3 i Human Paisley Ward reason for
encounter Cough and shortness of breath Primary Care Of
The Childbearing and childrearing family (Chamberlain
University) nov 2025
NR 602 week 3 iHuman Paisley Ward 16y F
History of Present Illness
Reason for Encounter Cough and shortness of breath
History of present illness Patient presents with cough x 3 weeks following
URI sx of runny nose and congestion that
resolved after 1 week. Developed shortness of
breath 3 days ago. Cough is dry, nonproductive,
and worse at night. She denies any relieving
factors for the cough and has not tried any
treatments. Shortness of breath is worse at night
and with exertion. Episodes last about a minute
or so and are relieved by rest. She denies chest
pain but describes chest tightness.
Past Medical History
Past Medical History Well-controlled eczema with no flare-ups in a few
years. Reactive airway with more frequent
episodes when she was younger; untreated due
to self-resolution and limited family resources
Hospitalizations/Surgeries No previous hospitalizations or surgeries
Medications
Medications No prescription or OTC medications or
supplements
Allergies
Allergies NKDA
, lOMoARcPSD| 16290539
Preventive Health
Preventive Health Vaccinations are UTD
Family History
Family History Father: 42yo, eczema
Mother: 42yo, no medical problems
M.Grandmother: 84yo, hypertension
M. Grandfather: 82yo, gout, hyperlipidemia
Unknown paternal grandparent history
Social History
Social History Lives in an apartment with her parents. She is a
high school student. She does not drink alcohol,
use drugs, or use tobacco products. She is
exposed to secondhand smoke daily.
Review of Systems
General Denies fatigue, weight loss or gain, fever, or night
sweats. She reports cough is disrupting her sleep.
Integumentary/Breast Denies rashes, lesions, moles, or skin changes.
HEENT/Neck Denies headache, vision changes, ear pain, hearing
problems, sinus problems, sore throat, or difficulty
swallowing.
Cardiovascular Denies chest pain, dizziness, palpitations, or
blue/cold fingers or toes. Reports chest tightness.
Respiratory Reports dry, nonproductive cough and shortness
of breath. Denies wheezing
Gastrointestinal Denies nausea, vomiting, diarrhea, constipation, or
abdominal pain.
Genitourinary Denies frequency, urgency, dysuria, or hematuria
Musculoskeletal Denies muscle pain or weakness. Denies joint pain,
swelling, or redness.
Allergic/Immunologic Denies allergies
Endocrine Denies heat or cold intolerances, increased thirst,
increased sweating, frequent urination, or change
in appetite.
Hematologic/Lymphatic Denies bruising or bleeding.
Neurologic Denies dizziness, fainting, seizures, weakness,
numbness, or tingling.
Psychiatric Denies anxiety, mood changes, or hallucinations.
Physical Exams
