Focused Exam Cough documentation_.pdf

6/4/2018 Focused Exam: Cough | Completed | Shadow Health


Focused Exam: Cough Results | Turned In
i i i i i i

Advanced i Health i Assessment i- iChamberlain, i NR509-April-2018
Return i to i Assignment




Your Results
i Lab iPass




Overview
Documentation / Electronic Health Record
i i i i


iTranscrip



t Document: iVitals Document: i Provider i Notes

Subjective iData iCollection

iObjective iData iCollection
Document: Provider Notes
i i


Education i & i Empathy
Student iDocumentation Model iDocumentation
Documentation
idays
Subjective
Self-Reflection
Daniel i"Danny i" iRivera, i8 iyear iold imale iof
iPuertoiRican idescent.

CC" ipatience iabuela ibrought ihim iin ibecause ihe ihas
ibeen ifeeling isick iand icoughing ia ilot iand ifeel ikind

iofitired."

HPI: i Cough i onset i 5 i days i ago, i pt i describe i cough"
igurgly iand iwatery" i. ireports isputum icolor iis iclear.

iReports i coughing i every i few i minutes i and i worse i at

inight. iPatient idenies ismoking ibut iexposed ito

isecondhand i smoke i in i the i house i through i father

i and igrandfather. i Reports i does i not i know i what

i makes i hisicough iworse. iAlleviating ifactors iof ithe

icough i is isome i cough i medicine i in i the i morning.

i Reports ihaving icough imedicine ieverything ifor ithe

ipast i5 idays, idescribes i it i as i purplish i in icolor i one

i spoon i fulliand i giving i my i mom. i Has i physical

i exercise i everydayistill iable ito irun iaround iand iplay

iand icough inot imaking iit idifficult ito iplay igets

ibored iwith ieasy ischool iwork. iReports i currently

i having i a i runny i nose iand ifrequent irhinorrhea

idenies iany isneezing.

Reports inasal idrainage iclear iand iwatery ialso
ithin.iReports ia i3/10 iin iRight iear. iDenies iany ipain

ito itheileft iear. iPatient ireports ihistory iof ifrequent

iear iinfections iaround i2 iyears iof iage.

Can iI iuse iany iear idrainage ior ihearing iproblems.
iHad ihearing itest iat ischool iapproximately iabout

iaimonth iago.

Current iMedication: iMulti ivitamin ievery iday i"
igummy idinosaur", icough imed ifor ithe ipast i5


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, 6/4/2018 Focused Exam: Cough | Completed | Shadow Health



Danny ireports ia icough ilasting ifour ito ifive idays. iHe idescribes ithe icough ias
i“watery iand igurgly.” iHe ireports ithe icough iis iworse iat inight iand ikeeps ihim

iup. iHe ireports igeneral ifatigue idue ito ilack iof isleep. iHe ireports ipain iin ihis iright

iear. iHe iis iexperiencing imild isoreness iin ihis ithroat. iHe ireports ihis imother

itreated ihis icough isymptoms iwith iover-the-counter imedicine, ibut iit iwas ionly

itemporarily ieffective. iHe ireports ifrequent icold iand irunny inose, iand ihe istates

ithat ihe ihad ifrequent iear iinfections ias ia ichild. iHe ireports ia ihistory iof

ipneumonia iin ithe ipast iyear. iHe ireports inormal ibowel imovements. iHe idenies

ifever, iheadache, i dizziness, i trouble i swallowing, inosebleed, iphlegm ior isputum,

ichest ipain, itrouble ibreathing iand iabdominal ipain. iHe idenies icough

iaggravation iwith iactivity.




This study source was downloaded by 100000835554553 from CourseHero.com on 01-13-2022 09:59:11 GMT -06:00

https://chamberlain.shadowhealth.com/assignment_attempts/3552952 2/4
https://www.coursehero.com/file/31530124/Focused-Exam-Cough-documentation-pdf/