Student Documentation Model Documentation
Focused Exam: Cough Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1
Return to Assignment (/assignments/313480/)
Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
Subjective
Dany is a 8 year old hispanic boy, brought into clinic by his grandmother. He is able to answer the questions independently and maintains eye contact. He reports a gurgly watery cough for the last 4-5 days. His throat is hurting with the cough, and is feeling tired. Difficult sleeping due to the cough. His mother gave him a “purple medicine” this morning, for the cough, although he doesn’t know the name of it. It has helped, but then his cough presents itself again. He has c/o right ear pain, that started yesterday. He has had hx of ear infections when he was 2 yo. He denies fever or chills, or watery eyes but states he gets the “cold” frequently. Denies chest pain or difficult breathing No allergies to meds or pollen Immunizations: updated PMHx; ear infections at childhood Surgical hx: none Social hx: Lives with parents, grandmother assists with care, when parents are at work. does not smoke, exposed to 2nd hand smoke from his Papi. Washes hands before eating or after restroom. No family history of asthma or allergies.
Danny reports a cough lasting four to five days. He describes the cough as “watery and gurgly.” He reports the cough is worse at n and keeps him up. He reports general fatigue due to lack of slee He reports pain in his right ear. He is experiencing mild soreness his throat. He reports his mother treated his cough symptoms wi over-the-counter medicine, but it was only temporarily effective. reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He reports a history of pneumo in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, trouble swallowing, nosebleed, phleg or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity.