![]() He describes the cough as “watery and gurgly.” He reports the cough is worse at night and keeps him up. Respiratory: Reports freqent cough, denies difficulty breathing, denies chest tightness, denies history of inhaler use or breathingĭanny reports a cough lasting four to five days. ![]() Denies nosebleeds, Reports runny nose, denies vision problems, Denies dizziness, denies watery eyes, denies eye redness, denies eye pain, denies sinus problems. HEENT: Denies ear popping, Reports history of frequent ear infections. Review of the Systems Constitutional: Denies fever, denies chillis, denies weigh loss or gain, denies night sweats. He reports having no barriers to health care. Patient reports father smokes cigars in the house. Social History: Patient lives in a house with parents and grandparents. He reports having pneumonia last that caused him to miss two weeks of school. Patient reports last known ear infection was when he was two years old. Past medical History: Frequent ear infections as small child. Home medications: Daily vitamin, over the counter antitussive medication Patient has had no exposure to sick individuals. He reports his mother treated his cough symptoms with over the counter cough medicaton that was temporarily effective. He reports pain in his right ear and mild soreness in his throat. He describe the cough as ” watery and gurgly” He reports being feeling tired because the cough is worse at night and keeps him up. ![]() HPI:Danny reports a cough lasting four to five days. Student DocumentationStudent Documentation Model DocumentationModel Documentation on our Help Desk for further information.ĭocument: Vitals Document: Provider Notes If you are are experiencing audio issues while using Safari, please visit this If you are are experiencing audio issues while using Safari, please visit this articlearticle on our Help Desk for further information. Focused Exam: Cough | Completed | Shadow Health Nursing Assignmentįocused Exam: Cough Results | Turned In Advanced Health Assessment – Fall 2019, NGR 6002 ![]()
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