Home medications: Daily vitamin, over the counter antitussive medication
Past medical History: Frequent ear infections as small child. Patient reports last known ear infection was when he was two years old. He reports having pneumonia last that caused him to miss two weeks of school.
Social History: Patient lives in a house with parents and grandparents. Patient reports father smokes cigars in the house. He reports feeling safe in his home. He reports having no barriers to health care .
Review of the Systems Constitutional: Denies fever, denies chillis, denies weigh loss or gain, denies night sweats. Reports feeling “kind of tired”
HEENT: Denies ear popping, Reports history of frequent ear infections. Denies ear surgery or ear tubes. Denies headaches. Denies nosebleeds, Reports runny nose, denies vision problems, Denies dizziness, denies watery eyes, denies eye redness, denies eye pain, denies sinus problems. denies hearing problems. Reports pain in right ear. Reports mild sore thoart.
Respiratory: Reports freqent cough, denies difficulty breathing, denies chest tightness, denies history of inhaler use or breathing
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.
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation / Electronic Health Record
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11/11/19, 3:44 PMFocused Exam: Cough | Completed | Shadow Health
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