Week 5 Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation SUBJECTIVE DATA:

Week 5 Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation SUBJECTIVE DATA:

Week 5

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

SUBJECTIVE DATA:

Chief Complaint (CC): Reports cough, runny nose, sore throat, and right ear pain.

History of Present Illness (HPI): Reports cough started five days ago with coughing

every few minutes. Reports cough is wet and clear sputum and worse at night. A runny

nose is frequent with thin clear discharge. Pain in the right ear is a 3/10 that started after

the cough with nasal discharge from the ear. Throat has now become sore with mild pain

when swallowing.

Medications: Pt. denies daily prescriptions. He takes a daily OTC multivitamin. Today

his mother gave him a cough medication that temporarily relieved the symptoms he was

experiencing.

Allergies: No known allergies to food, medication, or latex.

Past Medical History (PMH): History of pneumonia and frequent coughing.

Past Surgical History (PSH): No surgical history.

Sexual/Reproductive History: No sexual history

Personal/Social History: Pt. lives in a home with his mother, father, and grandparents.

His father is a cigar smoker, and the patient is exposed to secondhand smoke at times. Pt.

reports feeling safe and supported at home

Significant Family History: The mother reports her health is good with no significant

concerns. The father smokes tobacco and is moderately overweight, and being monitored

for prediabetes. The patient’s grandmother has hypertension. The grandfather has type 2

diabetes controlled with oral medications and diet.

Review of Systems:

General: Denies fever, chills, or recent weight loss.

HEENT: Pt. denies pain in his head. Pt. denies vision changes or eye complaints

bilaterally with no report of eye pain, redness, or eye drainage. Pt. reports right ear pain

that is 3/10. No left ear complaints. History of frequent ear infections noted, but without

the need for ear tubes or surgical intervention. Pt. denies hearing changes. Pt. reports thin

clear nasal drainage without congestion. No epistaxis was reported. Pt. reports throat to

be sore and experiencing minor pain with swallowing.

Respiratory: Denies difficulty breathing. Denies history of asthma. Productive cough

with wet clear sputum x 5 days reported.

Cardiovascular/Peripheral Vascular: No chest pain or cardiac history. Denies heart

palpitations or abnormal activity tolerance. Pt. denies swelling in extremities.

Psychiatric: No pertinent psychiatric complaints or history.

Neurological: No complaints of headache, dizziness, or seizures.

Lymphatics: Pt. denies painful or tender lymph nodes