*NURSING > SHADOW HEALTH > Shadow health Focused Exam Cough Documentation (All)

Shadow health Focused Exam Cough Documentation

Document Content and Description Below

Subjective Danny reports a cough starting four or five days ago. He describes the cough as "watery" and "gurgly" but non productive. He reports the cough is worse at night and keeps him up. He repo... rts fatigue due to the lack of sleep from his cough keeping him up at night. He reports his throat is sore, rated as a 2/10. He also reports pain in his right ear, rated as a 3/10. He reports his mother gave him over the counter cough medicine for his cough but it was only temporarily effective. He reports frequent cold and runny nose and states that he had frequent ear infections as a child. He reports having a runny nose often. He reports a history of pneumonia one time last year that was treated at an urgent care clinic. He reports normal bowel movements. He denies any previous hospitalizations. He denies any fever, headache, dizziness, chills, nausea, nosebleeds, or difficulty swallowing. He denies any phlegm or sputum, trouble breathing, chest pain, or abdominal pain. He reports exposure to Danny reports a cough lasting four to five days. He describes the cough as “watery and gurgly.” He reports the cough is worse at night and keeps him up. He reports general fatigue due to lack of sleep. He reports pain in his right ear. He is experiencing mild soreness in his throat. He reports his mother treated his cough symptoms with over-the-counter medicine, but it was only temporarily effective. He reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, trouble swallowing, nosebleed, phlegm or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity. [Show More]

Last updated: 2 years ago

Preview 1 out of 3 pages

Buy Now

Instant download

We Accept: