COURSE
NURS 6512 Advanced Health Assessment and Diagnostic
Focused Exam: Cough
CC: Coughing a lot and feeling tired
HPI: Danny Rivera is eight years old male of Puerto Rico origin presenting with “coughing and tiredness” noted five days ago. He describes Cough as “gurgle and watery” and worse during the nighttime. Reports cough looking purple after taking purple medicine given by mother with the taste of grape. No pain during coughing and last cough medicine I spoon endured this morning. Denies knowing the medication’s name, No one at home has a cough, but the running nose has been an ongoing issue. Patient reports father smoking cigars in the house, breathing the smoke and dislikes the smell, lives with mother and father, grandmother and grandfather, reports the previous cough, running nose but not that bad, denies stuffy nose, reports sore throat, denies swallowing problems but hurts a little due to sore throat.
Denies fever per mother this morning, reports right ear hurting a little bit but left one is okay, denies any drainage from the ears. However, the right ear hurts, reports pain of 3/10 from the right ear., reports throat pain of 2/10 and sore., denies headache, but reports of getting dizzy when spinning around.
Medications: 1 gummy Daily multivitamin, cough medicine (purple in color) 1 spoon
Allergies: No known allergies to food, medicine and seasonal
PMH: Pneumonia diagnosis in 2019 in Urgent care, no hospitalization, Childhood vaccines up to date
Social HX: Patients lives with parents, grandfather, grandmother. Attends 3rd grade in school and Tony is best friend. Grandparents care for Danny while parents are not home
Family History: Father-smoker, HTN, Asthma as child, hyperlipidemia……….………..please click the icon below to purchase full answer at $10