Feb 23, 2024 Shadow Health: Focused Exam: Cough Results Danny Riviera
Shadow Health: Focused Exam: Cough Results Danny Riviera
Subjective Data Collection: 21 of 21 (100.0%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Patient Data
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A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding: Established chief complaint
Finding: Reports cough (Found) Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: Do you have a cough?
History of Present Illness
Finding: Asked about onset of cough
Finding: Reports cough started 5 days ago (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How long have you had a cough?
Finding: Asked about frequency and duration of cough
Finding: Reports coughing every few minutes (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How frequently have you been coughing?
Finding: Asked about character of cough
Finding: Reports cough is wet (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your cough a wet cough?
Finding: Reports clear sputum (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you produce any phlegm or sputum with your cough?
Finding: Asked about aggravating factors for cough
Finding: Reports cough is worse at night (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your cough worse at night?
Finding: Reports exposure to secondhand smoke (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you around anyone who smokes at home?
Finding: Denies knowing what makes the cough worse (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What makes your cough worse?
Finding: Asked about relieving factors for cough
Finding: Denies resting relieves cough (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does resting help your cough?
Finding: Denies drinking water relieves cough (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does drinking water help your cough?
Finding: Asked about nasal symptoms
Finding: Reports current runny nose (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have a runny nose?
Finding: Denies sneezing (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Have you been sneezing?
Finding: Reports frequent runny nose (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you get runny noses often?
Finding: Followed up on nasal discharge
Finding: Reports nasal discharge is clear (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What color is your snot?
Finding: Reports nasal discharge is thin (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your snot thin?
Finding: Asked about ear symptoms
Finding: Reports pain in right ear (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have any ear pain?
Finding: Followed up on ear pain
Finding: Reports ear pain started yesterday (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How long have you had ear pain?
Finding: Reports ear pain is a 3 out of 10 (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Can you rate your ear pain on a scale?
Finding: Denies ear discharge (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have any ear discharge?
Finding: Asked about throat symptoms
Finding: Reports sore throat (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your throat sore?
Finding: Reports “a little” pain with swallowing (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does it hurt when you swallow?
Finding: Asked about allergies
Finding: Denies seasonal allergies (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have seasonal allergies?
Finding: Denies food allergies (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have food allergies?
Finding: Denies medication allergies (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you allergic to any medicine?
Finding: Denies allergies to animals (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you allergic to animals?
Finding: Denies latex allergy (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you allergic to latex?
Finding: Asked about contact with illnesses
Finding: Denies being around anyone ill at home (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is anyone sick at home?
Home Medications
Finding: Asked about home medications
Finding: Confirmed home medications (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: What medications do you take?
Finding: Reports taking a daily vitamin (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Do you take vitamins?
Finding: Reports taking cough medicine (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Are you taking medication for your cough?
Finding: Followed up on cough medicine
Finding: Reports cough medicine was purple (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: What color was the cough medicine?
Finding: Reports taking one spoonful of cough medicine (Available) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: How much cough medicine did you take?
Finding: Reports mother gave him the medicine (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Who gave you the cough medicine?
Finding: Reports cough medicine provided temporary relief (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Did the cough medicine make you feel better?
Past Medical History
Finding: Asked about relevant medical history
Finding: Denies asthma diagnosis (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have asthma?
Finding: Reports immunizations as current (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have current immunizations?
Finding: Reports past pneumonia and frequent coughs (Found) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have a history of respiratory problems?
Finding: Denies past hospitalizations (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you ever been to the hospital?
Social Determinants of Health
Finding: Asked about exposure to secondhand smoke
Finding: Reports father smokes cigars (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Who smokes at home?
Finding: Reports father sometimes forgets to take cigars outside (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Where does your father smoke?
Social History
Finding: Asked about living conditions
Finding: Reports living in a house with parents and grandparents (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Where do you live?
Finding: Reports feeling safe at home (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you feel safe at home?
Finding: Reports park with playground near home (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Is there anywhere near your home where you can play outside?
Review of Systems
Finding: Asked about constitutional health
Finding: Denies fever (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have a fever?
Finding: Denies chills (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have chills?
Finding: Reports feeling “kind of tired” (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have fatigue?
Finding: Denies night sweats (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have night sweats?
Finding: Denies weight loss (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Has your weight changed?
Finding: Denies appetite loss (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you lost your appetite?
Finding: Asked about review of systems for HEENT
Finding: Denies ear popping or crackling (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you hear any popping sounds?
Finding: Reports history of frequent ear infections (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you ever had ear infections?
Finding: Denies ear surgery or ear tubes (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you ever had surgery on your ears?
Finding: Denies headaches (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you get headaches?
Finding: Denies nosebleeds (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have nosebleeds?
Finding: Denies vision problems (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any problems with your vision?
Finding: Denies dizziness (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any dizziness?
Finding: Denies watery eyes (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have watery eyes?
Finding: Denies eye redness (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have eye redness?
Finding: Denies eye pain (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any eye pain?
Finding: Denies sinus pain (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any sinus pain?
Finding: Denies hearing problems (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any hearing problems?
Finding: Asked about review of systems for respiratory
Finding: Denies difficulty breathing (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have difficulty breathing?
Finding: Denies chest tightness (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have chest tightness?
Finding: Denies chest pain (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any chest pain?
Finding: Denies history of inhaler use or breathing treatments
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
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Chief Complaint (CC): “I have had a cough for five days now.”
History of Present Illness (HPI): Danny is a 14-year-old African-American male who presents with the complaint of a cough for five days. The cough is wet with clear sputum. Reports coughing every couple of minutes. The cough is worse at night with no known triggering factors. The cough is not relieved by rest or upon taking water. However, it is temporarily relieved by over-the-counter cough medications. It is associated with a runny nose, ear pain, sore throat, and a little pain while swallowing. The nasal discharge is thin and clear while the right ear pain began the previous day with a severity of 3 on a scale of 0-10. There is no associated sneezing or ear discharge. Denies contact with an individual with a chronic cough.
Medications: Daily vitamin and over-the-counter cough medication that his mother gave him.
Allergies: Denies seasonal allergies and allergies t
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