NURS 550 Danny Rivera Focused Note.

NURS 550 Danny Rivera Focused Note.Date of encounter: 22/AUG/2018 Patient Name or initials: Danny Rivera Informant: Informant is the patient, an 8-year-old Hispanic-American male. Chief Complaint (CC): "Been feeling sick. I have been coughing a lot. Feeling kind of tired." History of present illness (HPI): Patient presents with a cough that started five days ago. Reports his cough worse at night. Reports fatigue because “Coughing keeps him up at night.” Describes cough as productive and “gurgly and watery.” Reports clear sputum. Reports severity 5/10, and frequency is every few minutes. States cough “Stays the same” with activity. Denies chest pain or difficulty breathing. Reports pain to right ear with a 3/10 pain. Reports sore throat, pain of 2/10. No difficulty swallowing. Reports runny nose, clear drainage. Denies being around illness. No recent fever. Denies similar symptoms to pneumonia. Mother gave cough medicine once in am, offered some relief. He reports normal bowel movements. He denies headache, dizziness, nosebleed, phlegm, or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity. Allergies: No known drug, or food allergies noted. Medications: Patient takes a daily multivitamin and an OTC cough suppressant.