Document: Provider Notes – NURS 6512
Name: Danny Rivera
Focused Exam: Cough
case stu
Subjective
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 accident at age 52
(P) Grandfather: No known history
SH : He is a 3rd grader who resides with mother and father. Grandmother cares for him when parents are working. Father smokes cigars, but
mostly outside the home. He says, “they would make me cough if he smoked inside all the time.” He exercises in school daily, during gym
class. Primary language is English, but Spanish spoken at times in home.
ROS
General: Denies any fevers. Denies recent weight loss.
HEENT: Denies eye redness or drainage. Denies vision problems. Denies hearing problems. Problems with smell when congestion increased
Denies dryness to mouth. Denies increased thirst.
Cardiovascular: Denies orthopnea. Denies chest pain.
Gastrointestinal: Denies abdominal pain or discomfort. Denies N/V. Denies appetite problems. Last BM this morning.
Pulmonary: Clear nasal drainage that has worsened since cough started. He says, “My nose is always runny.” Productive cough of “slimy,
clear stuff “ some of the time. Cough worse at night. Denies breathing problems when lying flat. Denies SOB.
Allergies: Denies food and drug allergies. Denies latex allergy.
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Name: Danny Rivera
Focused Exam: Cough
case stu
Subjective
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 accident at age 52
(P) Grandfather: No known history
SH : He is a 3rd grader who resides with mother and father. Grandmother cares for him when parents are working. Father smokes cigars, but
mostly outside the home. He says, “they would make me cough if he smoked inside all the time.” He exercises in school daily, during gym
class. Primary language is English, but Spanish spoken at times in home.
ROS
General: Denies any fevers. Denies recent weight loss.
HEENT: Denies eye redness or drainage. Denies vision problems. Denies hearing problems. Problems with smell when congestion increased
Denies dryness to mouth. Denies increased thirst.
Cardiovascular: Denies orthopnea. Denies chest pain.
Gastrointestinal: Denies abdominal pain or discomfort. Denies N/V. Denies appetite problems. Last BM this morning.
Pulmonary: Clear nasal drainage that has worsened since cough started. He says, “My nose is always runny.” Productive cough of “slimy,
clear stuff “ some of the time. Cough worse at night. Denies breathing problems when lying flat. Denies SOB.
Allergies: Denies food and drug allergies. Denies latex allergy.
This study source was downloaded by 100000830772748 from CourseHero.com on 08-16-2022 03:23:57 GMT -05:00
C o p y r i g h t © 2 0 1 9 || S h a d o w h e a l t h . c o m
https://www.coursehero.com/file/72126067/Shadow-Health-Coughdocx/
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