Daniel Rivera Shadow health subjective data PDF

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Daniel Rivera Shadow health assessment subjective data week 6 NUR 509 chamberlain college...

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Daniel Rivera Subjective data Established chief complaint Reports cough

Asked about onset of cough Reports cough started 3 days ago

Asked about characteristics of cough Reports cough is wet Reports clear sputum with cough

Asked about frequency and duration of cough Reports coughing every few minutes Reports coughs last a few seconds

Asked about aggravating factors for cough Reports cough is worse at night Denies smoking Reports being exposed to secondhand smoke through father Reports he doesn't know what triggers the cough

Asked about exposure to germs Reports playing with an ill classmate

Asked about hand hygiene Reports infrequent hand washing Reports occasionally putting fingers in eyes, nose, or mouth

Asked about cough etiquette Denies covering mouth when coughing

Asked about relieving factors for cough Reports cough is temporarily relieved by cough medicine

Followed up on cough medicine Reports cough medicine was purple Reports taking one spoonful of cough medicine Reports mother gave him the medicine Reports only took the medicine this morning Denies home remedies

Asked about typical medication use Denies taking medication Reports taking daily vitamin

Asked about activity level Reports typical high activity level Reports activity level low since getting sick Reports still able to run or play Reports focusing in class is difficult

Asked about nasal symptoms Reports current runny nose Denies sneezing

Followed up on nasal discharge

Reports nasal discharge is clear Reports nasal discharge is thin

Asked about ear symptoms Denies ear pain Reports history of frequent ear infections Denies ear discharge Denies hearing problems

Asked about throat symptoms Reports sore throat Reports a little pain with swallowing

Asked about relevant medical history Reports frequent runny noses Reports past frequent coughs Reports past pneumonia Denies asthma diagnosis Reports immunizations as current

Asked about allergies Denies seasonal allergies Denies food allergies Denies medication allergies

Asked relevant family history Reports father has history of asthma Denies family history of allergies

Asked about constitutional health Denies chills Denies fever Reports feeling somewhat fatigued Denies night sweats Reports cough makes it difficult to sleep Denies swelling

Asked about additional review of systems for HEENT Reports frequent colds Denies headaches Denies nosebleeds Denies vision difficulty Denies dizziness Denies watery eyes Denies eye redness Denies eye pain Denies sinus pain

Asked about review of systems for respiratory Denies chest tightness Denies chest pain Denies difficulty breathing...