Shadow Health Exam: Cough Assessment

Shadow Health Focused Exam Cough 1. Established chief Reports cough complaint 2. Asked about on- Reports cough started 3 days ago set of cough 3. Asked about Reports cough is wet characteristics of Reports clear sputum with cough cough 4. Asked about fre- Reports coughing every few minutes quency and dura- Reports coughs last a few seconds tion of cough 5. Asked about ag- Reports cough is worse at night gravating factors Denies smoking for cough Reports being exposed to secondhand smoke through father Reports he doesn't know what triggers the cough 6. Asked about ex- Reports playing with an ill classmate posure to germs 7. Asked about hand hygiene Reports infrequent hand washing Reports occasionally putting fingers in eyes, nose, or mouth 8. Asked about cough etiquette Denies covering mouth when coughing 9. Asked about re- Reports cough is temporarily relieved by cough medicine lieving factors for cough 10. Followed up on Reports cough medicine was purple cough medicine Reports taking one spoonful of cough medicine Reports mother gave him the medicine Reports only took the medicine this morning Denies home remedies 1/3 11. Asked about typ- Denies taking medication ical medication Reports taking daily vitamin use 12. Asked about ac- Reports typical high activity level tivity level Reports activity level low since getting sick Reports still able to run or play Reports focusing in class is difficult 13. Asked about Reports current runny nose nasal symptoms Denies sneezing 14. Followed up on Reports nasal discharge is clear nasal discharge Reports nasal discharge is thin 15. Asked about ear Denies ear pain symptoms Reports history of frequent ear infections Denies ear discharge Denies hearing problems 16. Asked about Reports sore throat throat symptoms Reports a little pain with swallowing 17. Asked about rele- Reports frequent runny noses vant medical his- Reports past frequent coughs tory Reports past pneumonia Denies asthma diagnosis Reports immunizations as current 18. Asked about allergies Denies seasonal allergies Denies food allergies Denies medication allergies 19. Asked relevant family history Reports father has history of asthma Denies family history of allergies 20. Asked about con- Denies chills stitutional health Denies fever Reports feeling somewhat fatigued Denies night sweats 2/3 Reports cough makes it difficult to sleep Denies swelling 21. Asked about 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 22. Asked about re- Denies chest tightness view of systems Denies chest pain for respiratory Denies difficulty breathing 3/3