SH Focused Exam COUGH Danny Rivera 2018.

A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint • Finding: Established chief complaint • Finding: Reports cough (Found) Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source. Example Question: Do you have a cough? History of Presenting Illness • Finding: Asked about onset of cough • Finding: Reports cough started 3 days ago (Found) Pro Tip: Whenever you are assessing a symptom or a health condition, in this case the patient's cough, inquiring about onset assesses the severity and the progression of the problem.Example Question: How long have you had a cough? • Finding: Asked about characteristics of cough • Finding: Reports cough is wet (Available) Pro Tip: The characteristics of a cough, such as whether it is dry or wet, can indicate key information about the type of illness the patient has. Example Question: Is your cough a wet cough? • Finding: Reports clear sputum with cough (Found) Pro Tip: The characteristics of a cough, such as whether it is productive, can indicate key information about the type of illness the patient has. Example Question: Do you produce any phlegm or sputum with your cough? • Finding: Asked about frequency and duration of cough • Finding: Reports coughing every few minutes (Found) Pro Tip: Establishing how frequently Danny coughs will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers. Example Question: How frequently are you coughing? • Finding: