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