Shadow Health- Danny Rivera- Focused
Exam: Cough
Established chief complaint - Reports cough
Asked about onset of cough - Reports cough started 3 days ago
Asked about characteristics of cough - Reports cough is wet
Reports clear sputum with cough
Asked about frequency and duration of cough - Reports coughing every few minutes
Reports coughs last a few seconds
Asked about aggravating factors for cough - 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 - Reports playing with an ill classmate
Asked about hand hygiene - Reports infrequent hand washing
Reports occasionally putting fingers in eyes, nose, or mouth
Asked about cough etiquette - Denies covering mouth when coughing
Asked about relieving factors for cough - Reports cough is temporarily relieved by
cough medicine
Followed up on cough medicine - 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 - Denies taking medication
Reports taking daily vitamin
Asked about activity level - Reports typical high activity level
Reports activity level low since getting sick
Reports still able to run or play
Exam: Cough
Established chief complaint - Reports cough
Asked about onset of cough - Reports cough started 3 days ago
Asked about characteristics of cough - Reports cough is wet
Reports clear sputum with cough
Asked about frequency and duration of cough - Reports coughing every few minutes
Reports coughs last a few seconds
Asked about aggravating factors for cough - 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 - Reports playing with an ill classmate
Asked about hand hygiene - Reports infrequent hand washing
Reports occasionally putting fingers in eyes, nose, or mouth
Asked about cough etiquette - Denies covering mouth when coughing
Asked about relieving factors for cough - Reports cough is temporarily relieved by
cough medicine
Followed up on cough medicine - 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 - Denies taking medication
Reports taking daily vitamin
Asked about activity level - Reports typical high activity level
Reports activity level low since getting sick
Reports still able to run or play
