Danny Rivera Fundamentals of Nursing Practice Documentation Focused Exam: Cough | Completed | Shadow Health.

Documentation / Electronic Health Record Document: Vitals Document: Nursing Notes Objective Data Collection Education & Empathy Documentation Care Plan Document: Nursing Notes Student Documentation Model Documentation Subjective Danny Rivera is an 8-year-old male who presents for evaluation of a cough of onset 3 days ago. Patient reports a productive cough with "slimy, clear" sputum. The patient reports a sensation to cough "every few minutes" and his coughing spells last "a couple seconds". The patient reports an exacerbation of his symptoms at night causing him to have difficulty sleeping. The patient reports that his friend he played with a few days ago is also sick with symptoms of a cough and rhinorrhea. The patient reports that his mother has been giving him cough medicine which was noted by his grandmother to be children's Dimetapp daytime formula. The child last received the Dimetapp this morning and noted improvment of his symptoms after taking the medication. The patient notes associated symptoms of "feeling tired" but notes that he is able to play at school normally until he feels the urge to cough. He also notes associated "clear" watery rhinorrhea and a sore throat with exacerbation with swallowing. The patient notes a normal level of focus at school but reports it is "harder than normal" to pay attention due to freqwuent coughing. The patient denies any symptoms of sneezing, ear pain, ear drainage, hearing changes, fever, chills, night sweats, HA, vision changes, dizziness, eatery eyes, sinus pain, chest pain, or difficulty breathing. The patient was sent to my office for evaluation by his teacher due to persistent cough. He reports no other associated sx or complaints at this time. Contacted guardian: Patients grandmother reports a cough for the past 3 days and states that Danny "hasn't been himself".