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Document: Vitals Document: Provider Notes
Document: Provider Notes
Student DocumentationStudent Documentation Model DocumentationModel Documentation
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
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.
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation / Electronic Health Record
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11/11/19, 3:44 PMFocused Exam: Cough | Completed | Shadow Health
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Cardiovascular: Denies chest pain or chest discomfort
Mr. Rivera is pleasant and cooperative fatgued appearing young boy seated upright on the examination table. He is in no acute distress. He is alert. His speech is clear and coherent. He maintains eye contact throught the interview and examination. He offers information freely and without contradiction.
HEENT: scleara white, conjuctiva moist and pink bilaterally. Rhinorrhea with clear mucus, nasal mucosa is boggy bilaterally. Right tympanic membrane is erythematous with inflammation. Right cervical lymph node is enlarged with noted tenderness. oral mucosa mosit and pink. Tonsils 2+ with erythema and inflammation. Posterior pharynx is erythematous with cobblestoning. Fine bumps noted on tongue.
Vital signs Blood pressure 120/76 O2 saturation: 96% on room air Pulse 100 Respiratory rate: 28 Temperature; 37.2
Cardiovascular: S1, S2, no murmurs, gallops or rubs. Mild tachycardia
Respiratory: Chest is symmetrical with respirations. Increased respiratory rate. Audible coarse crackles in upper airway; bronchovesicular bilaterally, clears with cough. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FEV1:3.15L, FVC 3.91L( FEV1/FVC: 80.5%)
• General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable.
• HEENT: Mucus membranes are moist, clear nasal discharge. Redness, cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva. Right Tympanic membrane is red and inflamed. Right cervical lymph node enlarged with reported tenderness.
• Cardiovascular: S1, S2, no murmurs, gallops or rubs.
• Respiratory: Respiratory rate increased, but no acute distress. Able to speak in full sentences. Breath sounds clear to auscultation. Negative bronchophony. Chest wall resonant to percussion. Expected fremitus, equal bilaterally. Spirometry: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%)
My differentials include acute viral rhinopharyngitis. strep throat, allergic rhinitis, acute otitis media, allergies and asthma
My differentials include cold, strep throat, rhinitis, allergies and asthma based on abnormal findings affecting the ears, upper respiratory tract and lymphatic region.
Danny will receive a strep throat culture to rule out strep throat.
10 day dose of antibiotics for treatment of acute otitis media.
Refer for allergy tesing and pulmonary function test.
Encourage Danny to increase intake of water and other fluids and educate on frequent handwashing.
Recommend antitussive treatment at night to help with his sleep.
Danny should be referred for an allergy test to rule out allergies as well as a lung function test to rule out asthma. He should receive a strep culture to rule out strep throat. I recommend antitussive treatment at night to help with his sleep in addition to bed rest.
Rebecca Hall (14 Oct 2019, 10:17 AM CDT): Great interview, very thorough and flowed well. Documentation-you did a great job on your documentation-only comment I have is to include right and left on the exam-document negative findings for left ear and neck as well as pertinent negatives for all systems examined-I know Shadow does not do this but I want you to. include supporting positive or negatives for your differential diagnoses If you have not done so I highly recommend you view the recording of the soap documentation conference. There is much information on accurate and appropriate soap
Cough Assignment Task 1