Questions and Answers
What is the established chief complaint?
Cough
When did the cough start?
3 days ago
What are the characteristics of the cough?
Wet, clear sputum
How often does the patient cough and for how long?
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What factors aggravate the cough?
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Has the patient been exposed to germs?
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How frequently does the patient practice hand hygiene?
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The patient covers their mouth when coughing.
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What temporarily relieves the cough?
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What type of cough medicine did the patient take?
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The patient takes regular medication.
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What is the patient's activity level?
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What are the current nasal symptoms?
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What is the nature of the nasal discharge?
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Are there any ear symptoms?
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What throat symptoms does the patient report?
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What is the relevant medical history of the patient?
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The patient has seasonal allergies.
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What is the family history relevant to the patient's condition?
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What are the constitutional health findings?
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What additional review of systems was conducted for HEENT?
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The patient denies having ___ in the respiratory system.
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Study Notes
Chief Complaint
- Primary issue reported is a cough.
Onset of Cough
- Cough started 3 days prior to the assessment.
Cough Characteristics
- Described as a wet cough.
- Produces clear sputum.
Frequency and Duration
- Cough occurs every few minutes, lasting a few seconds each time.
Aggravating Factors
- Cough worsens at night.
- Patient denies smoking but is exposed to secondhand smoke from the father.
- Uncertain about specific cough triggers.
Exposure to Illness
- Recent contact with an ill classmate noted.
Hand Hygiene Practices
- Reports infrequent hand washing habits.
- Admits to occasionally touching eyes, nose, or mouth.
Cough Etiquette
- Fails to cover mouth while coughing.
Relieving Factors
- Cough temporarily relieved by cough medicine.
Cough Medicine Details
- Cough medicine described as purple.
- One spoonful administered, given by mother, taken only that morning.
- Patient denies using home remedies.
Medication Use
- No routine medication taken except for a daily vitamin.
Activity Level
- Typically high activity level, but reduced since illness.
- Continues to participate in activities like running and playing.
- Difficulty maintaining focus in class.
Nasal Symptoms
- Currently experiencing a runny nose, with no sneezing reported.
Nasal Discharge
- Nasal discharge is clear and thin.
Ear Symptoms
- No ear pain; however, there is a history of frequent ear infections.
- No ear discharge or hearing issues reported.
Throat Symptoms
- Experiences a sore throat and mild pain while swallowing.
Relevant Medical History
- Frequent runny noses and coughs previously experienced.
- History of pneumonia, but denies asthma diagnosis.
- Immunizations are up to date.
Allergies
- Denies seasonal, food, or medication allergies.
Family Medical History
- Father has a history of asthma; no family allergies reported.
Constitutional Health
- No chills, fever, or night sweats.
- Reports some fatigue and difficulty sleeping due to cough.
- No swelling reported.
HEENT Review
- Frequent colds reported; denies headaches, nosebleeds, vision difficulties, dizziness, watery eyes, eye redness, or pain, and sinus pain.
Respiratory Review
- Denies chest tightness, chest pain, or difficulty breathing.
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Description
Test your knowledge of Danny Rivera's focused exam regarding cough symptoms. This quiz includes various essential aspects such as the chief complaint, onset, characteristics, frequency, and duration of the cough. Perfect for nursing students and health professionals seeking to enhance their clinical assessment skills.
