Shadow Health- Danny Rivera- Focused Exam: Cough with complete solution Established chief complaint Answer- Reports cough
Asked about onset of cough Answer- Reports cough started 3 days ago
Asked about characteristics
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Shadow Health- Danny Rivera- Focused Exam: Cough with complete solution Established chief complaint Answer- Reports cough
Asked about onset of cough Answer- Reports cough started 3 days ago
Asked about characteristics of cough Answer- Reports cough is wet Reports clear sputum with cough
Asked about frequency and duration of cough Answer- Reports coughing every few minutes Reports coughs last a few seconds
Asked about aggravating factors for cough Answer- 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 Answer- Reports playing with an ill classmate
Asked about hand hygiene Answer- Reports infrequent hand washing
Reports occasionally putting fingers in eyes, nose, or mouth
Asked about cough etiquette Answer- Denies covering mouth when coughing
Asked about relieving factors for cough Answer- Reports cough is temporarily relieved by cough medicine
Followed up on cough medicine Answer- 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 Answer- Denies taking medication Reports taking daily vitamin
Asked about activity level Answer- Reports typical high activity level
Reports activity level low since getting sick
Reports still able to run or play
Reports focusing in class is difficult
Asked about nasal symptoms Answer- Reports current runny nose Denies sneezing
Followed up on nasal discharge Answer- Reports nasal discharge is clear Reports nasal discharge is thin
Asked about ear symptoms Answer- Denies ear pain
Reports history of frequent ear infections
Denies ear discharge
Denies hearing problems
Asked about throat symptoms Answer- Reports sore throat
Reports a little pain with swallowing
Asked about relevant medical history Answer- Reports frequent runny noses Reports past frequent coughs
Reports past pneumonia
Denies asthma diagnosis
Reports immunizations as current
Asked about allergies Answer- Denies seasonal allergies
Denies food allergies
Denies medication allergies
Asked relevant family history Answer- Reports father has history of asthma
Denies family history of allergies
Asked about constitutional health Answer- Denies chills
Denies fever
Reports feeling somewhat fatigued
Denies night sweats
Reports cough makes it difficult to sleep
Denies swelling
Asked about additional review of systems for HEENT Answer- Reports frequent colds
Denies headaches
Denies nosebleeds
Denies vision difficulty
Denies dizziness
Denies watery eyes
Denies eye redness
Denies eye pain
Denies sinus pain
Asked about review of systems for respiratory Answer- Denies chest tightness
Denies chest pain
Denies difficulty breathing
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