Patient chief complaint is shortness of breath and cough
Remember to ask about all systems in general
Ask mom about vaccines
Systems review
Cough for the last three weeks which has been getting worse. I've also had S
...
Patient chief complaint is shortness of breath and cough
Remember to ask about all systems in general
Ask mom about vaccines
Systems review
Cough for the last three weeks which has been getting worse. I've also had SOB when walking to
my next class at school. I have to stop and take a break
No, but I did have a runny nose and congestion 3 weeks ago. The congestion went away in a
week but the cough is still there
Anything make better or worse?
Not really, it has been constant but has been getting worse over the past three days and seems
to be worse at nights. 5
.What treatments have you had for your cough? Nothing
SOB x 3 days, It gets a little better when I stop walking and rest for a bit. It's a little worse at
night. Last few yrs, I have had a cough and SOB but it got better after a few days so I din not get
checked. This time its lasting longer. I also didn't want to stress out my parents bc they have to
work so much so I never told them.
Endorses hx of mild excema
MSAP- anxiety, tachypnea and 94% 02 sat???
16 year old female c/o a nonproductive cough x 3 weeks that is constant, and 3 days ago
became abruptly worse at night. She reports chest tightness but denies any pain. She reports
shortness of breath on exertion for three days that make her have to stop and take breaks while
walking, which helps ease the shortness of breath. She reports having had a runny nose and
congestion three weeks ago with resolution of the congestion but the cough remained.
She denies taking any medication or any treatments for any of her symptoms.
She reports having neighbors that smoke in her building and being able to smell the smoke from
every where in the building.
She has a PMH of eczema, and an episode of reactive airway disease three years ago in which
the symptoms resolved on their own without intervention.
16 year old female presenting with c/o a constant, nonproductive cough x 3 weeks that became
worse at night 3 days ago. She reports chest tightness and shortness of breath with mild
exertion for three days but denies any pain. She reports having had a runny nose and
congestion with cough three weeks ago that resolved on its own but the cough remained.
She denies taking any medication or any treatments for any of her symptoms.
She reports being exposed to cigarette smoke in her apartment building.
She has a PMH of eczema, and an episode of reactive airway disease three years ago in which
the symptoms resolved on their own without intervention.PW is a teenage female who is overweight but generally healthy and well groomed. She is alert,
oriented x 4. Height is 5'5 (165cm), 150.0lb (68.2kg)BMI of 25, BP is 112/82, heart rate 88,
respirations of 26, sp02 94%.
Negative for headaches, double or blurred vision, hearing problems, ea
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