Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data

Focused Examination: Cough – Danny Rivera Shadow Health Objective and Subjective Data

Objective Data Collection: 15 out of 15 (100.0%)

– Inspected eyes and orbital area
– No visible abnormal findings

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– Sclera
– White

– Conjunctiva
– Moist and pink

– Conjunctival Discharge
– No discharge

– Inspected nasal cavities
– Color: Pink
– Discharge: No discharge
– Turbinate Patency: Patent
– Observations: No additional visible abnormal findings

– Inspected ears
– Right: Tympanic Membrane Appearance: No visible abnormal findings
– Right: Cone Of Light: 5:00
– Right: Discharge: No discharge
– Left: Auditory Canal Color: Pink
– Left: Tympanic Membrane Color: Pearly gray
– Left: Tympanic Membrane Appearance: No visible abnormal findings
– Left: Cone Of Light: 7:00
– Left: Discharge: No discharge

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– Inspected mouth and throat
– Oral Mucosa: Moist and pink
– Tonsils: No visible abnormal findings
– Throat Color: Pink
– Throat Texture: No abnormal findings
– Post Nasal Drip: No discharge

– Inspected neck
– Symmetry: Symmetric
– Appearance: No visible abnormal findings

– Inspected chest
– Symmetry: Symmetric
– Appearance: No visible abnormal findings

– Auscultated breath sounds
– Breath Sounds: Present in all areas
– Adventitious Sounds: No adventitious sounds
– Location: All areas clear

– Auscultated for bronchophony
– Bronchophony: Negative

– Auscultated heart sounds
– Heart Sounds: S1 and S2 audible
– Extra Heart Sounds: No extra sounds

– Percussed chest wall
– Observations: All areas resonant
– Location: No areas of dullness

– Measured diaphragmatic excursion
– Range: 3-5 cm

– Palpated sinuses
– Frontal: None reported
– Maxillary: None reported

– Palpated lymph nodes
– Head And Neck: No palpable nodes
– Supraclavicular: No palpable nodes
– Axillary: No palpable nodes

– Palpated fremitus
– Symmetry: Equal bilaterally
– Vibration: Expected fremitus

– Palpated chest expansion
– Symmetry: Equal bilaterally

Subjective Data Collection: 22 out of 22 (100.0%)

– Chief Complaint: Reports cough

– History of Presenting Illness
– Onset of cough: Started 3 days ago
– Characteristics of cough: Wet, clear sputum with cough
– Frequency and duration of cough: Coughing every few minutes, coughs last a few seconds
– Aggravating factors for cough: Cough is worse at night, exposed to secondhand smoke through father, doesn’t know what triggers the cough
– Exposure to germs: Played with an ill classmate
– Hand hygiene: Infrequent hand washing
– Cough etiquette: Doesn’t cover mouth when coughing
– Relieving factors for cough: Cough is temporarily relieved by cough medicine
– Followed up on cough medicine: Cough medicine was purple, took one spoonful of cough medicine, mother gave him the medicine, only took the medicine this morning
– Home remedies: Denies home remedies
– Typical medication use: Denies taking medication, reports taking daily vitamin
– Activity level: Typical high activity level, activity level low since getting sick, still able to run or play, focusing in class is difficult
– Nasal symptoms: Current runny nose, denies sneezing
– Followed up on nasal discharge: Nasal discharge is clear, nasal discharge is thin
– Ear symptoms: Denies ear pain, reports history of frequent ear infections, denies ear discharge, denies hearing problems
– Throat symptoms: Reports sore throat, a little pain with swallowing
– Past Medical History
– Relevant medical history: Reports frequent runny noses, reports past frequent coughs, reports past pneumonia, denies asthma diagnosis, reports immunizations as current
– Allergies: Denies seasonal allergies, denies food allergies, denies medication allergies
– Family history: Reports father has a history of asthma, denies family history of allergies
– Review of Systems
– Constitutional health: Denies chills, denies fever, reports feeling somewhat fatigued, denies night sweats, reports cough makes it difficult to sleep, denies swelling
– Additional review of systems for HEENT: Reports frequent colds, denies headaches, denies nosebleeds, denies vision difficulty, denies dizziness, denies watery eyes, denies eye redness, denies eye pain, denies sinus pain
– Review of systems for respiratory: Denies chest tightness, denies chest pain, denies difficulty breathing

NRNP-6540 Week 9: Knowledge Check Quiz ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERS

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Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data

Objective Data Collection: 15 of 15 (100.0%)