Focused Exam: Cough Assignment

Focused Exam: Cough Assignment

Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.

  • Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
  • Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis? Focused Exam: Cough Assignment
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  • Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing tReview the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
    Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
    Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

11/11/19, 3:44 PMFocused Exam: Cough | Completed | Shadow Health

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Focused Exam: Cough Results | Turned In Advanced Health Assessment – Fall 2019, NGR 6002

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Your Results Lab Pass Lab Pass

Document: Vitals Document: Provider Notes

Document: Provider Notes

Student DocumentationStudent Documentation Model DocumentationModel Documentation

Subjective

HPI:Danny reports a cough lasting four to five days. He describe the cough as ” watery and gurgly” He reports being feeling tired because the cough is worse at night and keeps him up. He reports pain in his right ear and mild soreness in his throat. He reports his mother treated his cough symptoms with over the counter cough medicaton that was temporarily effective. He reports frequent cold and runny nose. Patient has had no exposure to sick individuals. Patient denies having allergies Focused Exam: Cough Assignment

Home medications: Daily vitamin, over the counter antitussive medication

Past medical History: Frequent ear infections as small child. Patient reports last known ear infection was when he was two years old. He reports having pneumonia last that caused him to miss two weeks of school.

Social History: Patient lives in a house with parents and grandparents. Patient reports father smokes cigars in the house. He reports feeling safe in his home. He reports having no barriers to health care .

Review of the Systems Constitutional: Denies fever, denies chillis, denies weigh loss or gain, denies night sweats. Reports feeling “kind of tired”

HEENT: Denies ear popping, Reports history of frequent ear infections. Denies ear surgery or ear tubes. Denies headaches. Denies nosebleeds, Reports runny nose, denies vision problems, Denies dizziness, denies watery eyes, denies eye redness, denies eye pain, denies sinus problems. denies hearing problems. Reports pain in right ear. Reports mild sore thoart.

Respiratory: Reports freqent cough, denies difficulty breathing, denies chest tightness, denies history of inhaler use or breathing

Danny reports a cough lasting four to five days. He describes the cough as “watery and gurgly.” He reports the cough is worse at night and keeps him up. He reports general fatigue due to lack of sleep. He reports pain in his right ear. He is experiencing mild soreness in his throat. He reports his mother treated his cough symptoms with over-the-counter medicine, but it was only temporarily effective. He reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, trouble swallowing, nosebleed, phlegm or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity Focused Exam: Cough Assignment.

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