COUGH

DIGITAL CLINICAL EXPERIENCE: FOCUSED EXAM: COUGH

Subjective

Danny Rivera is an 8 years old boy presenting with a wet cough. He reports that the cough has lasted three days. He describes the cough as wet and gurly.

Objective

The cough is temporarily treated by the children's cough medicine his mother gave him. He reports that the cough is not aggravated by activity. He reports the cough gets worse at night, which keep him up at night. He reports tenderness of his throat. He reports a history of frequent rhinorrhea and cough. Risk factor includes second-hand smoke from father, history of pneumonia in the past year, and being overwiegt for his age.

Assessment

He has no acute respiratory distress, his lungs are clear to auscultation and is afebrile, He has current rhinorrhea, examination of the nose reveals boggy turbinate. His throat appears red with visible cobblestoning in the back. His respiratory rate is inscreased, and he present mild tachycardia.

Plan

I recomende calling his grandmother to pick him up from school. He should see his primary care provider within the next few days for an evaluation and tests to rule out asthma and allergies. In the meantime, he should be allowed to rest and should be given cough medicine as needed.

RUBRIC FOR GRADING

Subjective Documentation in Provider Note Template: Subjective narrative documentation in Provider Note Template is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.= Documentation is detailed and organized with all pertinent information noted in professional language....Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Objective Documentation in Provider Notes - this is to be completed using the documentation template that is provided. Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use "WNL" or "normal". You only need to examine the systems that are pertinent to the CC, HPI, and History. Diagnostic result - Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned. Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). = Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language....Each system assessed is clearly documented with measurable details of the exam.