Digital Clinical Experience: Focused Exam: Cough
Catherine2
WK5DANNYRIVERADCEHEENTExamDocument.docxDocument: Provider Notes
Objective
Vital signs: B/P 120/76, pulse 100, respiration 28, Temp. 37.2C (99.0F), oxygen saturation 98%, spirometry FVC: 3.91 L FEV1 3.15 L (FEV1/FVC: 80.5%) Increase respiration at 28, mild tachycardia at 100 bpm. Appearance: stable, seated on the examination table calm and able to make full complete sentences. Redness observed in the nostrils. Breathe sounds clear upon auscultation, alert and oriented x3. Head full of hair and clean, neck smooth and jugular vein non-distended.
Assessment
Cough, Fatigue, Sore throat, Rhinitis, Allergies.
Plan
Order lab work for the throat culture to R/O strep. Cough medicine to be given at night. Encourage fluid intake. Educate family about administration of medication. Encourage family members not to smoke in the house. Follow up with your primary physician.
Documentation / Electronic Health Record
Document: Vitals
Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
Subjective
Daniel who preferred to be called "Danny" Rivera is 8 years old male Spanish whose country of origin is Puerto Rico.
Medical History: No surgery, no prior hospitalization, had pneumonia last year and was treated at urgent care clinic.
Allergies: No known allergies.
Chief Complaint: Danny stated, "my abuela brought me here because I've been feeling sick" "I have been coughing a lot, and I feel kind of tired". He is in 3rd grade.
History of present condition: Cough which started about 5 days ago. Patient stated that cough is "gurgle and watery", and the color of cough is "gross, slimy stuff". As per patient, he takes cough medicine given by his mom in the morning, and the color of the medicine is purple. He stated that the medicine helps the cough a little and he does not remember what it is called. Patient stated, "most times I sleep for about 8 hours", and said, "I haven't been able to sleep much because of my cough". Patient reported having running nose and does not have seasonal allergy. Nasal Cavity color is erythema, color of the nasal drainage is clear, watery and thin. Reported pain in the right ear and rated it 3 on a scale of 0-10. Denied pain on the left ear. Patient's father and grandfather smoke around him.
Family History: Mother has type 2 diabetes, HTN, hypercholesterolemia, spinal stenosis, , obesity.
Father: Is a smoker, HTN, hypercholesterolemia, asthma as a child.
Maternal grand-mother: Type diabetes, HTN.
Maternal grand-father: Smoker, eczema
Paternal grand-mother: died in a car accident at age 52 years old.
Paternal grand-father: No known history.
Social history:
School attendance record: Danny has been out of school for two weeks last year due to pneumonia. He lives with his parents and grand-mother. Grand-mother takes care of him while his parents go to work. He speaks English and family use Spanish in conjunction with English.
N/A
Objective
Vital signs: B/P 120/76, pulse 100, respiration 28, Temp. 37.2C (99.0F), oxygen saturation 98%, spirometry FVC: 3.91 L
FEV1 3.15 L (FEV1/FVC: 80.5%). Weight: 90 lbs., Ht. 4' 2”.
Increase respiration at 28, mild tachycardia at 100 bpm. Appearance: stable, seated on the examination table calm and able to make full complete sentences. Redness observed in the nostrils. Breathe sounds clear upon auscultation, alert and oriented x3. Head full of hair and clean, neck smooth and jugular vein non-distended.
N/A
Assessment
Cough, Fatigue, Sore throat, Rhinitis, Allergies.
N/A
Plan
Order lab work for the throat culture to R/O strep. Cough medicine to be given at night. Encourage fluid intake. educate family about administration of medication. Encourage family member not to smoke in the house.
Follow up with your primary physician.
