lOMoARcPSD|44613495
Advanced Health Assessment (Walden University)
Name: Danny Rivera
Section: NURS 6512
Week 5
Shadow Health Digital Clinical Experience Focused Exam: Cough
Documentation
SUBJECTIVE DATA: Cough
Chief Complaint (CC): Cough
History of Present Illness (HPI): This is an 8-year-old Puerto Rican male,
who was brought in today by his grandmother with a persistent productive
cough that started about 4-5 days ago. He reports a mild sore throat, rates
pain 2/10, food and liquid do not make a difference in his cough. He denies
trauma or sick contacts. No fever or muscle aches. He reports a runny nose
with clear drainage, with mild throat soreness that he rates a 2/10. He has a
productive cough with clear sputum, that keeps him up at night, he also
reports right ear pain. He states his mother gave him “purple” cough syrup,
but it helped minimally. He denies fever, chills, body aches and has no
change in appetite or ability to swallow. He also denies sick contacts and
reports he washes his hands frequently.
Medications: Daily multivitamin; cough syrup (purple?)
Allergies: None
Past Medical History (PMH): Frequent ear infections as a toddler, last one
around 2 years old; Pneumonia 2020 (treated at urgent care clinic)
Past Surgical History (PSH): No surgical history or prior hospitalizations
Sexual/Reproductive History:
, lOMoARcPSD|44613495
Personal/Social History: Danny is in the 3rd grade, missed 2 weeks of
school last year due to pneumonia. He lives with is mother, father who work
during the day and his grandmother provides child-care while parents work.
English is the primary language spoken in the home, however some Spanish
is used.
Immunization History: Current and up to date with all age appropriate
vaccinations. No flu vaccine in the last 12 months.
Significant Family History: Mother: type 2 diabetes, HTN,
hypercholesterolemia, spinal stenosis, obesity. Father: smoker, HTN,
hypercholesterolemia, asthma as a child. Maternal grandmother: type 2
diabetes, HTN. Maternal grandfather: smoker, eczema. Paternal
grandmother: died at age 52 in a car accident. Paternal grandfather: history
unknown.
Review of Systems:
General: Breathing non labored, afebrile, coughs every few seconds,
cough is dry, coarse and non-productive, while in clinic.
HEENT: Positive for R ear pain, slight sore throat
Respiratory: Positive for productive cough with clear sputum,
Cardiovascular/Peripheral Vascular: Denies chest pain, no
murmurs or rubs, no dyspnea
Psychiatric: Denies being sad or feeling anxious
Neurological: Denies seizures, syncope, no head trauma reported
Lymphatics: Denies blood transfusions, denies anemia
OBJECTIVE DATA:
Physical Exam: Vital signs: 37.2, 120/76, 100, 28, 96% on RA, 4’2”, 90
lbs., BMI
General: This is a well-developed, well nourished 8 year old Puerto Rican
boy who is alert and cooperative. He is a good historian and answers all
Advanced Health Assessment (Walden University)
Name: Danny Rivera
Section: NURS 6512
Week 5
Shadow Health Digital Clinical Experience Focused Exam: Cough
Documentation
SUBJECTIVE DATA: Cough
Chief Complaint (CC): Cough
History of Present Illness (HPI): This is an 8-year-old Puerto Rican male,
who was brought in today by his grandmother with a persistent productive
cough that started about 4-5 days ago. He reports a mild sore throat, rates
pain 2/10, food and liquid do not make a difference in his cough. He denies
trauma or sick contacts. No fever or muscle aches. He reports a runny nose
with clear drainage, with mild throat soreness that he rates a 2/10. He has a
productive cough with clear sputum, that keeps him up at night, he also
reports right ear pain. He states his mother gave him “purple” cough syrup,
but it helped minimally. He denies fever, chills, body aches and has no
change in appetite or ability to swallow. He also denies sick contacts and
reports he washes his hands frequently.
Medications: Daily multivitamin; cough syrup (purple?)
Allergies: None
Past Medical History (PMH): Frequent ear infections as a toddler, last one
around 2 years old; Pneumonia 2020 (treated at urgent care clinic)
Past Surgical History (PSH): No surgical history or prior hospitalizations
Sexual/Reproductive History:
, lOMoARcPSD|44613495
Personal/Social History: Danny is in the 3rd grade, missed 2 weeks of
school last year due to pneumonia. He lives with is mother, father who work
during the day and his grandmother provides child-care while parents work.
English is the primary language spoken in the home, however some Spanish
is used.
Immunization History: Current and up to date with all age appropriate
vaccinations. No flu vaccine in the last 12 months.
Significant Family History: Mother: type 2 diabetes, HTN,
hypercholesterolemia, spinal stenosis, obesity. Father: smoker, HTN,
hypercholesterolemia, asthma as a child. Maternal grandmother: type 2
diabetes, HTN. Maternal grandfather: smoker, eczema. Paternal
grandmother: died at age 52 in a car accident. Paternal grandfather: history
unknown.
Review of Systems:
General: Breathing non labored, afebrile, coughs every few seconds,
cough is dry, coarse and non-productive, while in clinic.
HEENT: Positive for R ear pain, slight sore throat
Respiratory: Positive for productive cough with clear sputum,
Cardiovascular/Peripheral Vascular: Denies chest pain, no
murmurs or rubs, no dyspnea
Psychiatric: Denies being sad or feeling anxious
Neurological: Denies seizures, syncope, no head trauma reported
Lymphatics: Denies blood transfusions, denies anemia
OBJECTIVE DATA:
Physical Exam: Vital signs: 37.2, 120/76, 100, 28, 96% on RA, 4’2”, 90
lbs., BMI
General: This is a well-developed, well nourished 8 year old Puerto Rican
boy who is alert and cooperative. He is a good historian and answers all
