SH Focused Exam COUGH shadow health

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A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint  Finding: Established chief complaint  Finding: Reports cough (Found) Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source. Example Question: Do you have a cough? History of Presenting Illness  Finding: Asked about onset of cough  Finding: Reports cough started 3 days ago (Found) Pro Tip: Whenever you are assessing a symptom or a health condition, in this case the patient's cough, inquiring about onset assesses the severity and the progression of the problem. Example Question: How long have you had a cough?  Finding: Asked about characteristics of cough  Finding: Reports cough is wet (Available) Pro Tip: The characteristics of a cough, such as whether it is dry or wet, can indicate key information about the type of illness the patient has. Example Question: Is your cough a wet cough?  Finding: Reports clear sputum with cough (Found) Pro Tip: The characteristics of a cough, such as whether it is productive, can indicate key information about the type of illness the patient has. Example Question: Do you produce any phlegm or sputum with your cough?  Finding: Asked about frequency and duration of cough  Finding: Reports coughing every few minutes (Found) Pro Tip: Establishing how frequently Danny coughs will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers. Example Question: How frequently are you coughing?  Finding: Reports coughs last a few seconds (Available) Pro Tip: Establishing how long Danny's coughs last will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers. Example Question: How long do your coughs last?  Finding: Asked about aggravating factors for cough  Finding: Reports cough is worse at night

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