Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

Subjective Data Collection: 20 of 20 (100.0%)

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Experts chose these subjects as vital components of a complete and thorough interview with this patient.

Patient Data

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A combination of open and closed questions will produce more accurate patient data. The following information pertains to the patient’s case. Subjective Data from Danny Rivera’s Pediatric Cough Shadow Health Assessment

Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

Chief Complaint

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Finding:

Determined the main complaint

Finding:

Coughing reports

(Found)

Pro Tip: Inquire about your patient’s cough and voice quality to help guide your assessment. Subjective Data from Danny Rivera’s Pediatric Cough Shadow Health Assessment

Question Example:

Do you have a cold or a cough?

Current Illness History

Finding:

When asked about the onset of the cough,

Finding:

Coughing began five days ago, according to reports.

(Found)

Pro Tip: Inquiring about the onset of a symptom or a health condition while evaluating a symptom or a health condition examines the severity and progression of the problem.

Question Example:

How long have you been coughing?

Finding:

When asked about the frequency and length of coughing,

Finding:

Coughing every few minutes is reported.

(Found)

Pro Tip: Making a timeline for Danny’s coughing will show how long he has been experiencing these symptoms and may point to potential triggers. Subjective Data from Danny Rivera’s Pediatric Cough Shadow Health Assessment

Question Example:

How frequently have you coughed?

Finding:

When asked about the cough’s characteristics,

Finding:

The cough is watery, according to reports.

(Found)

Pro Tip: Inquire about your patient’s cough and voice quality to help guide your assessment. Subjective Data from Danny Rivera’s Pediatric Cough Shadow Health Assessment

Question Example:

Is your cough watery or dry?

Finding:

There has been a report of clear sputum with a cough.

(Found)

Pro Tip: Asking if your patient’s cough is productive should help you make an informed decision.

Question Example:

Is there any phlegm or mucus in your cough? Subjective Data from Danny Rivera’s Pediatric Cough Shadow Health Assessment

Finding:

When asked about the causes of coughing,

Finding:

Coughing is said to be worse at night.

(Found)

Pro Tip: Making a timeline for Danny’s coughing will show how long he has been experiencing these symptoms and may point to potential triggers.

Question Example:

Is your cough getting worse at night?

Finding:

Exposure to secondhand smoking is reported.

(Found)

Tobacco usage puts the patient at risk for a variety of medical issues. This risk factor is assessed by inquiring about all types of tobacco products.

Question Example:

Do you use tobacco?

Finding:

Reports of not knowing specific causes that aggravate the cough

(Found)

Follow-up questions will allow Danny to describe his ailment, experience, or symptoms more thoroughly and clearly. Knowing what causes Danny’s cough to worsen will enable you to treat his symptoms more effectively.

Question Example:

What causes your cough to worsen?

Finding:

When asked about cough relievers,

Finding:

Cough “remains the same” with rest, according to reports.

(Available)

Pro Tip: Inquiring about what relieves the patient’s main complaint can help determine the efficacy of potential treatments and may provide important information into the ailment itself.

Question Example:

Is it true that resting helps your cough?

Finding:

Cough “remains the same” despite drinking water, according to reports.

(Available)

Pro Tip: Inquiring about what relieves the patient’s main complaint can help determine the efficacy of potential treatments and may provide important information into the ailment itself. Subjective Data from Danny Rivera’s Pediatric Cough Shadow Health Assessment

Question Example:

Is drinking water beneficial to your cough?

Finding:

When questioned about nasal symptoms,

Finding:

The current runny nose is reported

(Found)

Pro Tip: Enquiring your patient if his nose is running will help you assess his symptoms and potential triggers. Subjective Data from Danny Rivera’s Pediatric Cough Shadow Health Assessment

Question Example:

Have you had a runny nose?

Finding:

He denies sneezing

(Found)

Pro Tip: Inquiring your patient if he has been sneezing will help you assess the symptoms he is experiencing as well as potential reasons.

Question Example:

Have you been sneezing recently?

Finding:

There has been a lot of talk about rhinorrhea.

(Found)

Pro Tip: Knowing how frequently your patient encounters symptoms, such as a runny nose, will help you treat them more successfully.

Question Example:

Do you frequently have runny noses?

Finding:

Nasal discharge was followed upon.

Finding:

The nasal discharge is reported to be precise.

(Found)

Pro Tip: Inquire about your patient’s specific symptoms and how they present, such as the consistency of his nasal discharge, to comprehend his symptoms better.

Question Example:

What is the hue of your snot?

Finding:

The nasal discharge is thin, according to reports.

(Found)

Pro Tip: Inquire about your patient’s specific symptoms and how they present, such as the consistency of his nasal discharge, to comprehend his symptoms better.

Question Example:

Is your snot slender?

Finding:

When questioned about ear symptoms,

Finding:

Right ear discomfort is reported.

(Found)

Pro Tip: Ear pain may indicate an ear infection, in which the middle ear becomes blocked with fluid and mucous, impairing hearing. Subjective Data on Danny Rivera’s Pediatric Cough Shadow Health Assessment. If you ask Danny if he feels ear pain, it could indicate an ear infection and the cause of his hearing changes.

Question Example:

Do you suffer from ear pain?

Finding:

I followed up on the ear pain.

Finding:

Reports of ear pain began yesterday.

(Available)

Pro Tip: Knowing how long your patient has been in pain will help you evaluate how quickly treatment is required.

Question Example:

How long have you been suffering from ear pain?

Finding:

A pain level of 3 is reported for ear pain.

(Available)

Pro Tip: It is critical to assess the severity of your patient’s condition to determine how quickly therapy is required and how best to address it.

Question Example:

How severe is your ear pain?

Finding:

Ear discharge is denied.

(Found)

Pro Tip: Inquire about your patient’s specific symptoms and how they manifest, such as if he has ear discharge, to understand his symptoms better. Subjective Data on Danny Rivera’s Pediatric Cough Shadow Health Assessment.

Question Example:

Is there any ear discharge?

Finding:

When asked about throat discomfort,

Finding:

Reports of a painful throat

(Found)

Pro Tip: Your assessment should be guided by questions concerning the patient’s mouth and throat.

Question Example:

Is your throat aching?

Finding:

Swallowing causes “a little” pain, according to the patient.

(Found)

Pro Tip: Inquire about your patient’s specific symptoms and how they manifest, such as if he has ear discharge, to understand his symptoms better.

Question Example:

Is it painful to swallow?

Danny Rivera’s Medical History Pediatric Cough Shadow Health Assessment Subjective Data

Finding:

Medication use has been confirmed

Finding:

Medication confirmation

(Found)

Pro Tip: Knowing what medications a patient is taking, if any, is an essential part of your entire health history and will help you avoid adverse drug interactions.

Question Example:

What medications are you now taking?

Finding:

Reports of taking a vitamin daily

(Found)

Pro Tip: It’s crucial to specifically ask about vitamin or supplement use because patients don’t often perceive these to be “medicine.”

Question Example:

Do you take vitamin supplements?

Finding:

Takes cough medicine, according to reports

(Found)

Pro Tip: Inquiring particularly about drugs used to treat an illness is an excellent method to ensure that a patient remembers all of his meds.

Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

Question Example:

Are you taking any cough medicine?

Finding:

Cough medication was followed upon.

Finding:

According to reports, cough medication was purple.

(Found)

Pro Tip: Inquiring about how the patient has been managing their pain allows you to gauge their present state and approach self-care. The outcomes of their past treatment may aid in your diagnosis and the formulation of their current treatment plan and provide an opportunity to educate the patient on effective self-care habits.

Question Example:

What color was the cough syrup?

Finding:

One spoonful of cough medication is said to be taken.

(Found)

Pro Tip: Inquiring about how the patient has been managing their pain allows you to gauge their present state and approach self-care. The outcomes of their past treatment may aid in your diagnosis and the formulation of their current treatment plan and provide an opportunity to educate the patient on effective self-care habits.

Question Example:

How much cough syrup did you take?

Finding:

According to reports, his mother gave him the medication.

(Found)

Pro Tip: Inquiring about how the patient has been managing their pain allows you to gauge their present state and approach self-care. The outcomes of their past treatment may aid in your diagnosis and the formulation of their current treatment plan and provide an opportunity to educate the patient on effective self-care habits.

Question Example:

Who gave you the cough syrup?

Finding:

According to reports, cough medication gave brief alleviation.

(Available)

Pro Tip: Inquiring about how the patient has been managing their pain allows you to gauge their present state and approach self-care. The outcomes of their past treatment may aid in your diagnosis and the formulation of their current treatment plan and provide an opportunity to educate the patient on effective self-care habits—personal Data on Danny Rivera’s Pediatric Cough Shadow Health Assessment.

Question Example:

Did you feel better after using the cough medicine?

Finding:

When asked about allergies,

Finding:

Seasonal allergies are denied.

(Found)

Seasonal allergies can cause symptoms like a runny nose, cough, and discomfort. If you ask Danny if he has seasonal allergies, you can narrow down the list of likely triggers for his symptoms.

Question Example:

Do you suffer from seasonal allergies?

Finding:

Food allergies are denied.

(Found)

Pro Tip: Knowing whether or not your patient has food allergies is an important and relevant medical history. Inquiring about your patient’s dietary sensitivities will allow you to treat him more successfully.

Question Example:

Do you have any food sensitivities?

Finding:

Denies having any drug allergies

(Found)

Pro Tip: Knowing if your patient has any medication sensitivities is an important and relevant medical history. Inquiring about your patient’s medication allergies will allow you to treat him more efficiently.

Question Example:

Do you have any medication allergies?

Finding:

Animal allergies are denied.

(Available)

Pro Tip: Asking about animal allergies is vital for a child with respiratory difficulties because the problem could be caused or exacerbated by a family pet or recent animal exposure.

Question Example:

Do you have an allergy to animals?

Finding:

Denial of latex allergies

(Available)

In a hospital context, where several tools contain latex parts, it is critical to confirm the lack or existence of a latex allergy.

Question Example:

Do you have a latex allergy?

Finding:

When asked about any relevant medical history,

Finding:

Denies being diagnosed with asthma

(Found)

Pro Tip: Asthma is a severe medical condition that can be fatal if not treated properly. Regardless of the patient’s presenting ailment, identifying existing medical issues is crucial to treat the patient effectively. Even if the patient is not aware of any current symptoms, specific questions concerning previous medical problems should be asked.

Question Example:

Do you have asthma?

Finding:

Current immunizations are reported.

(Found)

Pro Tip: A health assessment should include an assessment of the patient’s immunization status to identify diseases to which the patient is susceptible.

Question Example:

Do you have up-to-date immunizations?

Finding:

Past pneumonia and persistent coughs have been reported.

(Found)

Pro Tip: Respiratory disorders severely limit one’s capacity to engage in routine daily activities. It is critical to determine the patient’s health issues to provide safe and effective care.

Question Example:

Do you have a history of breathing issues?

Finding:

Denies previous hospitalizations

(Available)

Pro Tip: Inquiring about past hospitalizations will give you a more comprehensive grasp of the patient’s medical history while also informing your judgment of their major complaint.

Question Example:

Have you ever visited a hospital?

History of Society

Finding:

When asked about secondhand smoking exposure,

Finding:

According to reports, the father smokes cigars.

(Found)

Second hand smoke puts the patient at risk for various medical diseases and can aggravate breathing problems associated with a respiratory ailment. Knowing about irritating exposure in the home, such as smoke, will assist you in identifying potential sources of Danny’s complaint.

Question Example:

Who smokes in the house?

Finding:

According to reports, the father occasionally forgets to take smokes outdoors.

(Available)

Second hand smoke puts the patient at risk for various medical diseases and can aggravate breathing problems associated with a respiratory ailment. Knowing about irritating exposure in the home, such as smoke, will assist you in identifying potential sources of Danny’s complaint.

Question Example:

Where does your father get his cigarettes?

System Evaluation

Finding:

When questioned about general symptoms

Finding:

Frequent colds are reported

(Found)

Pro Tip: Inquire about the patient’s vulnerability to colds to help guide your evaluation.

Question Example:

Do you have colds all the time?

Finding:

Denies having a fever

(Found)

Pro Tip: Obtaining a brief history of your patient’s symptoms can assist you in treating him more effectively. By asking Danny if he has a temperature, you can see how his symptoms appear.

Question Example:

Have you got a fever?

Finding:

Denies having chills

(Found)

Pro Tip: Obtaining a brief history of your patient’s symptoms can assist you in treating him more effectively. You can see how his symptoms materialize by asking Danny if he has chills.

 Subjective Data on Danny Rivera Pediatric Cough Shadow Health Assessment

Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data on Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data on Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data on Danny Rivera

Question Example:

Do you get chills?

Finding:

Feeling “sort of fatigued,” according to sources.

(Found)

Pro Tip: Obtaining a brief history of your patient’s symptoms can assist you in treating him more effectively. Inquiring about Danny’s weariness will reveal how his symptoms appear.

Question Example:

Do you feel tired?

Finding:

Denies having night sweats

(Found)

Pro Tip: Obtaining a brief history of your patient’s symptoms can assist you in treating him more effectively. By asking Danny if he experiences night sweats, you can see how his symptoms appear.

Question Example:

Do you suffer from night sweats?

Finding:

Denies having lost weight

(Available)

Pro Tip: Obtaining a brief history of your patient’s symptoms can assist you in treating him more effectively. By asking Danny if he has lost weight, you can see how his symptoms appear.

Question Example:

Have you slimmed down?

Finding:

Denies any decrease in appetite

(Available)

Pro Tip: Obtaining a brief history of your patient’s symptoms can assist you in treating him more effectively. Inquiring into Danny’s hunger will reveal how his symptoms appear.

Question Example:

Do you have a bad case of the munchies?

Finding:

Inquired about a system evaluation for HEENT

Finding:

Refuses to accept ear popping or crackling.

(Available)

Pro Tip: Inquiring about your patient’s specific symptoms and how they present, such as if he has any ear popping, will assist you in comprehending his symptoms.

Question Example:

Are you hearing any popping noises?

Finding:

Describes the history of recurring ear infections

(Available)

Pro Tip: Inquiring about your patient’s unique symptoms and how they manifest, such as if he has ear infections, will assist you in comprehending his symptoms.

Question Example:

Have you ever gotten an ear infection?

Finding:

Ear surgery or ear tubes are not permitted.

(Available)

Pro Tip: It is critical to ask your patient about previous surgeries to understand the scope of previous treatment better and rule out any potential complications that may be causing the patient’s condition.

Question Example:

Have you ever had your ears operated on?

Finding:

Denies having headaches

(Found)

Pro Tip: Headaches are a frequent complaint that various benign diseases can cause. However, headaches can be a symptom of underlying severe neurological disorders such as cerebral hemorrhage, meningitis, or brain tumors. They may also be an indication of sinus infection.

Question Example:

Do you have headaches?

Finding:

Denies nosebleeds

(Found)

Pro Tip: Infected sinuses might appear as nose difficulties. Inquiring about Danny’s nasal symptoms elicits information about his sinuses and potential sinus disorders. Subjective Data on Danny Rivera’s Pediatric Cough Shadow Health Assessment.

Question Example:

Do you have any nosebleed seats?

Finding:

Denies having vision difficulties

(Found)

Pro Tip: Eye or vision impairments can impair one’s ability to function and pose a significant safety risk.

Question Example:

Do you suffer from any eyesight issues?

Finding:

He denies feeling dizzy.

(Found)

Asking about dizziness checks for inner ear, neurological, or cardiovascular issues.

Question Example:

Do you experience dizziness?

Finding:

Denies having watery eyes

(Found)

Pro Tip: Eye or vision impairments can impair one’s ability to function and pose a significant safety risk.

Question Example:

Do you have swollen eyes?

Finding:

Denies redness of the eyes

(Found)

Pro Tip: Eye or vision impairments can impair one’s ability to function and pose a significant safety risk.

Question Example:

Do you have redness in your eyes?

Finding:

Denies having eye pain

 

(Found)

Tip: Sinusitis can cause pressure behind the eyes, resulting in eye pain. Inquiring about Danny’s eye pain elicits information regarding likely symptoms.

Question Example:

Do you have any eye problems?

Finding:

Denies having sinus pain

(Found)

Pro Tip: Sinus infections can cause nose difficulties. Inquiring about Danny’s nasal symptoms elicits information about his sinuses and potential sinus disorders.

Question Example:

Do you have any nasal issues?

Finding:

Denies having hearing issues.

(Found)

Pro Tip: Inquiring about your patient’s specific symptoms and how they manifest, such as hearing problems, will assist you in comprehending his symptoms.

Question Example:

Do you have any issues with your hearing?

Finding:

When asked about a review of respiratory systems,

Finding:

He denies having trouble breathing.

(Found)

Pro Tip: It’s critical to inquire about instances of shortness of breath because inadequate breathing can be fatal. Respiratory or heart disorders, allergies, or exercise can cause shortness of breath.

Question Example:

Do you have trouble breathing?

Finding:

He denies having chest tightness.

(Found)

Chest pain might be caused by heart problems, muscle inflammation, gastrointestinal trouble, or respiratory difficulties. If you have chest tightness, inquiring about its location, characteristics, and connected circumstances can help you determine what’s causing it—subjective Data on Danny Rivera’s Pediatric Cough Shadow Health Assessment.

Question Example:

Do you have a tight chest?

Finding:

He denies having chest pain.

(Found)

Chest pain might be caused by heart problems, muscle inflammation, gastrointestinal trouble, or respiratory difficulties. If you have chest pain, inquiring about its location, characteristics, and connected circumstances can help you determine what’s causing it.

Question Example:

Do you experience any aches and pains in your chest?

Finding:

There is no history of inhaler use or breathing therapies reported.

(Available)

Pro Tip: Respiratory disorders severely limit one’s capacity to engage in routine daily activities. It is critical to determine the patient’s health issues to provide safe and effective care.

Question Example:

Have you ever taken an inhaled medicine?

History of the Family

Finding:

When questioned about important family history

Finding:

There have been reports of not being near someone who is ill at home.

(Available)

Pro Hint:

Question Example:

Is anyone ill in your household?

Finding:

According to reports, the father suffered asthma as a child.

(Found)

Pro Tip: Medical disorders in a patient’s immediate family can signify high-risk factors for various medical conditions in the patient.

Question Example:

Do you have an asthmatic family history?

Finding:

Denies any allergy history in her family.

(Found)

Pro Tip: Medical disorders in a patient’s immediate family can signify high risk factors for various medical conditions in the patient. Subjective Data on Danny Rivera’s Pediatric Cough Shadow Health Assessment.

Question Example:

Do you have a history of allergies in your family?

Finding:

Home pets are not permitted.

Subjective Data from Danny Rivera’s Pediatric Cough Shadow Health Assessment

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