Shadow Health. Physical Assessment and Anatomy. Focused Exam_ Cough Results. Completed Subjective Data Collection. 20 of 20. Score 100.0%

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Shadow Health. Physical Assessment and Anatomy. Focused Exam_ Cough Results. Completed Subjective Data Collection. O Subjective Data Collection Objective Data Collection Education & Empathy Do... cumentation Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports cough History of Present Illness Asked about onset of cough Reports cough started 5 days ago Asked about frequency and duration of g every couple minutes Asked about character of cough Reports cough is wet Reports clear sputum with cough Subjective Data Collection: 20 of 20 (100.0%) © Shadow Health 2018 ® Reports cough is worse at night Reports exposure to secondhand smoke Reports not knowing specific triggers that make the cough worse Asked about relieving factors for cough Reports cough "stays the same" with rest Reports cough "stays the same" despite drinking water Asked about nasal symptoms Reports current runny nose Denies sneezing Reports frequent rhinorrhea Followed up on nasal discharge Reports nasal discharge is clear Reports nasal discharge is thin Asked about ear symptoms Reports pain in right ear Followed up on ear pain Reports ear pain started yesterday Reports pain rating of 3 for ear pain Denies ear discharge Asked about throat symptoms Reports sore throat Reports "a little" pain with swallowing Medical History Confirmed use of medications Confirms medications Reports taking a daily vitamin Reports taking cough medicine Followed up on cough medicine Reports cough medicine was purple Reports taking one spoonful of cough medicine Reports mother gave him the medicine Reports cough medicine provided temporary relief Asked about allergies Denies seasonal allergies Focused Exam: Cough | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/4028681 2 of 4 10/31/2018, 2:17 PMAsked about relevant medical history Denies asthma diagnosis Reports immunizations as current Reports past pneumonia and frequent coughs Denies past hospitalizations Social History Asked about exposure to secondhand smoke Reports father smokes cigars Reports father sometimes forgets to take cigars outside Review of Systems Asked about general symptoms Reports frequent colds Denies fever Denies chills Reports reports feeling "kind of tired" Denies night sweats Denies weight loss Denies watery eyes Denies eye redness Denies eye pain Reports history of frequent ear infections Denies ear surgery or ear tubes Asked about review of systems for respiratory Denies difficulty breathing Denies chest tightness Denies chest pain Reports no history of inhaler use or breathing treatments Family History Asked about relevant family history Reports not being around anyone ill at home Reports father had asthma as a child Denies family history of allergies Denies pets at home Focused Exam: Cough | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/4028681 3 of 4 10/31/2018, 2:17 PMComments [Show More]

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