c
96%
Medication: Denies
Food: Denies
Environment: Denies
History of Present Illness (HPI)
Chief Complaint (CC)
Cough
CC is a BRIEF statement identifying
why the patient is here - in the
patient’s own words - f
...
c
96%
Medication: Denies
Food: Denies
Environment: Denies
History of Present Illness (HPI)
Chief Complaint (CC)
Cough
CC is a BRIEF statement identifying
why the patient is here - in the
patient’s own words - for instance
"headache", NOT "bad headache for 3
days”. Sometimes a patient has more
than one complaint. For example: If
the patient presents with cough and
sore throat, identify which is the CC
and which may be an associated
symptom
Onset
Cough started 5 days ago
Location
throat
Duration
Coughing every few minutes lasting 1-2min , for the past five days.
Characteristics
Productive cough rated a 5 out of 10 with clear and thin sputum, cough
worsens at night. Associated symptoms of sore throat and earache,(gargly and
watery associated with sore throat)
Aggravating Factors
Worse at night. Reports cough stays the same no matter what I do. (cough at
night think CHF, GERD, Asthma…)
Relieving Factors
Cough medicine “helped a little”
Treatment
resting
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic)
Dosage
Frequency
Length of Time
Used
Reason for Use
Gummy multivitamin
2-4 gummies
daily
Unable to
answer my
question when
asked.
“to stay healthy”
Cough medicine
“ a spoonful”
One time
“Once this AM”
Cough
N/A
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