Shadow Health- Danny Rivera- Focused
Exam: Cough
Established chief complaint - Answer Reports cough
Asked about onset of cough - Answer Reports cough started 3 days ago
Asked about characteristics of cough - Answer Reports cough is wet
Reports clear sputum with cough
Asked about frequency and duration of cough - Answer Reports coughing every few
minutes
Reports coughs last a few seconds
Asked about aggravating factors for cough - Answer Reports cough is worse at night
Denies smoking
Reports being exposed to secondhand smoke through father
Reports he doesn't know what triggers the cough
Asked about exposure to germs - Answer Reports playing with an ill classmate
Asked about hand hygiene - Answer Reports infrequent hand washing
Reports occasionally putting fingers in eyes, nose, or mouth
Asked about cough etiquette - Answer Denies covering mouth when coughing
Asked about relieving factors for cough - Answer Reports cough is temporarily relieved
by cough medicine
Followed up on cough medicine - Answer Reports cough medicine was purple
Reports taking one spoonful of cough medicine
Reports mother gave him the medicine
Reports only took the medicine this morning
Denies home remedies
Asked about typical medication use - Answer Denies taking medication
Reports taking daily vitamin
Asked about activity level - Answer Reports typical high activity level
Reports activity level low since getting sick
Reports still able to run or play
Reports focusing in class is difficult
Asked about nasal symptoms - Answer Reports current runny nose
Denies sneezing
Followed up on nasal discharge - Answer Reports nasal discharge is clear
Exam: Cough
Established chief complaint - Answer Reports cough
Asked about onset of cough - Answer Reports cough started 3 days ago
Asked about characteristics of cough - Answer Reports cough is wet
Reports clear sputum with cough
Asked about frequency and duration of cough - Answer Reports coughing every few
minutes
Reports coughs last a few seconds
Asked about aggravating factors for cough - Answer Reports cough is worse at night
Denies smoking
Reports being exposed to secondhand smoke through father
Reports he doesn't know what triggers the cough
Asked about exposure to germs - Answer Reports playing with an ill classmate
Asked about hand hygiene - Answer Reports infrequent hand washing
Reports occasionally putting fingers in eyes, nose, or mouth
Asked about cough etiquette - Answer Denies covering mouth when coughing
Asked about relieving factors for cough - Answer Reports cough is temporarily relieved
by cough medicine
Followed up on cough medicine - Answer Reports cough medicine was purple
Reports taking one spoonful of cough medicine
Reports mother gave him the medicine
Reports only took the medicine this morning
Denies home remedies
Asked about typical medication use - Answer Denies taking medication
Reports taking daily vitamin
Asked about activity level - Answer Reports typical high activity level
Reports activity level low since getting sick
Reports still able to run or play
Reports focusing in class is difficult
Asked about nasal symptoms - Answer Reports current runny nose
Denies sneezing
Followed up on nasal discharge - Answer Reports nasal discharge is clear
