Name: Danny Rivera
Section: Week 5 - Focused Exam: Cough
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