nurs 6222 danny rivera cough soap note advanced health assessment 2022nurs 6222 danny rivera cough soap note advanced health assessment 2022nurs 6222 danny rivera cough soap note advanced health ass
Danny Rivera Cough SOAP
Note
George Washington University
NURS6222: Advanced Health
Assessment 4/4/22 COUGH SOAP NOTE 1
Subjective Information: Identifying Information: Visit on 4/4/22 at 2pm. 8-year-old Hispanic-American male presents as the patient, seems reliable, brought into office by his grandmother. Is currently in third grade. CC: “I have been coughing a lot.”
HPI: Patient presents with a cough beginning 5 days ago. Cough reportedly worse at night. Reports fatigue due to cough at night time and not sleeping. Cough is described as productive and “gurgly and watery.” Sputum is clear. Coughs every few minutes and no aggravation of cough with activity. Denies chest pain or difficulty breathing. Reports right ear pain 3/10. Throat pain 2/10. No difficulty swallowing. Admits to rhinorrhea, clear drainage. Denies recent exposure to anyone who was recently ill. No reports of recent fever. Reports that his mother administered cough medicine this morning, with some relief.
Medications:
Daily Multivitamin and PO over the counter cough suppressant (medication name and dose unknown- Purple)
Allergies:
Denies any drug, food, or environmental allergies.
PMH:
Denies prior hospitalizations. History of Chickenpox at age 6. Treated at an urgent care 1 year ago for pneumonia. Patient acknowledges a history of recurrent ear infections at a younger age. PSH: Denies PSH
Significant Family History: Mother: Alive - Diabetes, hypercholesterolemia, hypertension, spinal stenosis, obesity.
Father: alive – smoker, hypertension, hypercholesterolemia, asthma as a child. Maternal Grandmother: Alive – type two diabetes, Hypertension.
Maternal grandfather: Alive – smoker, eczema.
Paternal grandmother: Deceased – car accident age 52.
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