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Shadow health Focused Exam Cough Documentation
Advanced Health assessment (NP 762)
MGH Institute of Health Professions
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Focused Exam: Cough
Documentation / Electronic Health Record
Document: Vitals Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
Subjective Danny reports a cough starting four or five days ago. He describes the cough as "watery" and "gurgly" but non productive. He reports the cough is worse at night and keeps him up. He reports fatigue due to the lack of sleep from his cough keeping him up at night. He reports his throat is sore, rated as a 2/10. He also reports pain in his right ear, rated as a 3/10. He reports his mother gave him over the counter cough medicine for his cough but it was only temporarily effective. He reports frequent cold and runny nose and states that he had frequent ear infections as a child. He reports having a runny nose often. He reports a history of pneumonia one time last year that was treated at an urgent care clinic. He reports normal bowel movements. He denies any previous hospitalizations. He denies any fever, headache, dizziness, chills, nausea, nosebleeds, or difficulty swallowing. He denies any phlegm or sputum, trouble breathing, chest pain, or abdominal pain. He reports exposure to
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.
Student Documentation Model Documentation
secondhand smoke, but denies anything aggravating his cough.
Objective General survey: Alert and oriented X3, fatigued appearing young boy sitting on nursing bench, appears stable and in no apparent distress, coughing every few minutes. HEENT: Mucous membranes are moist, clear nasal discharge. Redness and cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva. Right tympanic membrane is red and inflamed. Right cervical lymph node is enlarged and tender. Cardiovascular: S1, S2, no gallops, murmurs, or rubs. Respiratory: Mild tachypnea, but no acute distress, able to speak in full sentences. Breath sounds clear to auscultation in all lung fields, chest wall resident to percussion. Negative bronchophony. Expected fremitus, equal bilaterally. Spirometry: FEV1: 1 L FVC: 1 FEV1/FVC ratio: 87%
- General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable. • HEENT: Mucus membranes are moist, clear nasal discharge. Redness, cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva. Right Tympanic membrane is red and inflamed. Right cervical lymph node enlarged with reported tenderness. • Cardiovascular: S1, S2, no murmurs, gallops or rubs. • Respiratory: Respiratory rate increased, but no acute distress. Able to speak in full sentences. Breath sounds clear to auscultation. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FEV1: 3 L, FVC 3 (FEV1/FVC: 80%)
Assessment Differentials include cold, pharyngitis, rhinitis, allergies, and asthma based on abnormal findings in the upper respiratory tract, right ear, and right cervical lymphatic region.
My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting the ears, upper respiratory tract and lymphatic region.
Plan Danny should receive a strep culture to rule out strep throat. I recommend an antitussive at night to help with sleep in addition to rest He should be referred for a lung function test to rule out asthma, as well as an allergy test to rule out allergies. Schedule follow-up in one week if symptoms do not improve or get worse.
Danny should be referred for an allergy test to rule out allergies as well as a lung function test to rule out asthma. He should receive a strep culture to rule out strep throat. I recommend antitussive treatment at night to help with his sleep in addition to bed rest.
Shadow health Focused Exam Cough Documentation
Course: Advanced Health assessment (NP 762)
University: MGH Institute of Health Professions
