NURS 6512 Shadow Health, Cough Document: Provider Notes – NURS 6512
Focused Exam: Cough Subjective Danny Rivera CC: “Cough” HPI: An 8-year-old Puerto Rican male presents to the clinic with grandmother for complaints of a cough that started 4-5 days ago. Associated symptoms are right ear pain 3/10 and sore throat. Also says that cough is keeping him up at night. Throat pain started 5 days ago, “when my cough started.” His ear started hurting yesterday. His mother gave him some purple cough syrup that “helped a little,” but started back again. Cough is worse at night. He denies being around anyone with an illness recently PMH: Dx with Pneumonia last year, treated at an urgent care. He was out of school for 2 weeks Childhood immunizations up to date Influenza vaccine not received in last 12 months Denies surgeries or hospitalizations Medications: Daily Multivitamin: Gummy dinosaurs FH: Mother: Type II Diabetes, HTN, Hypercholesterolemia, spinal stenosis, and obesity Father: Smoker, HTN, hypercholesterolemia, asthma as a child (M) Grandmother: Type II Diabetes, HTN (M) Grandfather: Smoker, Eczema, Asthma. (P) Grandmother: Died in a car a
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