Shadow Health - Danny Rivera Cough Exam

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.