Shadow Health - Danny Rivera - Focused Exam Cough(STUDY CASE)

Shadow Health - Danny Rivera -
Focused Exam Cough(STUDY CASE)


Established chief complaint
What brings you in today?
Finding:
Reports cough
Asked about onset of cough
How long have you had a cough?
Finding:
Reports cough started 5 days ago
Asked about frequency and duration of cough
How frequently have you been coughing?
Finding:
Reports coughing every few minutes
Asked about character of cough
Is your cough a wet cough?
Finding:
Reports cough is wet

Do you produce any phlegm or sputum with your cough?
Finding:
Reports clear sputum
Asked about aggravating factors for cough
Is your cough worse at night?
Finding:
Reports cough is worse at night

, Are you around anyone who smokes at home?
Finding:
Reports exposure to secondhand smoke

Do you know what makes your cough worse?
Finding:
Denies knowing what makes the cough worse
Asked about relieving factors for cough
Does resting help your cough?
Finding:
Denies resting relieves cough

Does drinking water help your cough?
Finding:
Denies drinking water relieves cough
Asked about nasal symptoms
Do you have a runny nose?
Finding:
Reports current runny nose

Have you been sneezing?
Finding:
Denies sneezing

Do you get runny noses often?
Finding:
Reports frequent runny nose
Followed up on nasal discharge
What color is your snot?
Finding:
Reports nasal discharge is clear