Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

Established chief complaint

• 
  

  Finding:

  Reports cough

  (Found)

  Pro Tip: Asking about the characteristics of your patient’s cough and voice quality should guide your assessment. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

  Example Question:

  Do you have a cough?

• 
  

  Finding:

  Asked about onset of cough

• 
  

  Finding:

  Reports cough started 5 days ago

  (Found)

  Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem.

  Example Question:

  How long have you had a cough?

• 
  

  Finding:

  Asked about frequency and duration of cough

• 
  

  Finding:

  Reports coughing every couple minutes

  (Found)

  Pro Tip: Establishing a timeline for Danny’s coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

  Example Question:

  How frequently have you been coughing?

• 
  

  Finding:

  Asked about character of cough

• 
  

  Finding:

  Reports cough is wet

  (Found)

  Pro Tip: Asking about the characteristics of your patient’s cough and voice quality should guide your assessment. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

  Example Question:

  Is your cough a wet cough?
• 
  

  Finding:

  Reports clear sputum with cough

  (Found)

  Pro Tip: Asking if your patient’s cough is productive should guide your assessment.

  Example Question:

  Do you produce any phlegm or sputum with your cough? Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

• 
  

  Finding:

  Asked about aggravating factors for cough

• 
  

  Finding:

  Reports cough is worse at night

  (Found)

  Pro Tip: Establishing a timeline for Danny’s coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.

  Example Question:

  Is your cough worse at night?
• 
  

  Finding:

  Reports exposure to secondhand smoke

  (Found)

  Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking about all types of tobacco products assesses this risk factor.

  Example Question:

  Do you smoke?
• 
  

  Finding:

  Reports not knowing specific triggers that make the cough worse

  (Found)

  Pro Tip: Follow-up questions will enable Danny to more fully and specifically describe his condition, experience, or symptoms. Establishing what makes Danny’s cough worse will allow you to more effectively treat his symptoms.

  Example Question:

  What makes your cough worse?

• 
  

  Finding:

  Asked about relieving factors for cough

• 
  

  Finding:

  Reports cough “stays the same” with rest

  (Available)

  Pro Tip: Asking what relieves the patient’s chief complaint will determine the efficacy of possible treatment and may provide important insight into the condition itself.

  Example Question:

  Does resting help your cough?
• 
  

  Finding:

  Reports cough “stays the same” despite drinking water

  (Available)

  Pro Tip: Asking what relieves the patient’s chief complaint will determine the efficacy of possible treatment and may provide important insight into the condition itself. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

  Example Question:

  Does drinking water help your cough?

• 
  

  Finding:

  Asked about nasal symptoms

• 
  

  Finding:

  Reports current runny nose

  (Found)

  Pro Tip: Asking your patient if his nose is running will allow you to determine the symptoms he is experiencing and possible triggers. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

  Example Question:

  Do you have a runny nose?
• 
  

  Finding:

  Denies sneezing

  (Found)

  Pro Tip: Asking your patient if he has been sneezing will allow you to determine the symptoms he is experiencing and possible triggers.

  Example Question:

  Have you been sneezing?
• 
  

  Finding:

  Reports frequent rhinorrhea

  (Found)

  Pro Tip: Establishing how frequently your patient experiences symptoms, like a runny nose, will most effectively enable you to treat your patient’s symptoms.

  Example Question:

  Do you get runny noses often?

• 
  

  Finding:

  Followed up on nasal discharge

• 
  

  Finding:

  Reports nasal discharge is clear

  (Found)

  Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like the character of his nasal discharge, will help you to understand his symptoms.

  Example Question:

  What color is your snot?
• 
  

  Finding:

  Reports nasal discharge is thin

  (Found)

  Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like the character of his nasal discharge, will help you to understand his symptoms.

  Example Question:

  Is your snot thin?

• 
  

  Finding:

  Asked about ear symptoms

• 
  

  Finding:

  Reports pain in right ear

  (Found)

  Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data. Asking Danny if he has ear pain might indicate a possible ear infection and a reason for changes in his hearing.

  Example Question:

  Do you have any ear pain?

• 
  

  Finding:

  Followed up on ear pain

• 
  

  Finding:

  Reports ear pain started yesterday

  (Available)

  Pro Tip: It is important to know how long your patient has suffered pain to determine how urgently treatment is needed.

  Example Question:

  How long have you had ear pain?
• 
  

  Finding:

  Reports pain rating of 3 for ear pain

  (Available)

  Pro Tip: It is important to determine the severity of your patient’s paint to determine how urgently treatment is needed and how best to address it.

  Example Question:

  How bad is your ear pain?
• 
  

  Finding:

  Denies ear discharge

  (Found)

  Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has ear discharge, will help you to understand his symptoms. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

  Example Question:

  Do you have any ear discharge?

• 
  

  Finding:

  Asked about throat symptoms

• 
  

  Finding:

  Reports sore throat

  (Found)

  Pro Tip: Asking about the patient’s mouth and throat should guide your assessment.

  Example Question:

  Is your throat sore?
• 
  

  Finding:

  Reports “a little” pain with swallowing

  (Found)

  Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has ear discharge, will help you to understand his symptoms.

  Example Question:

  Does it hurt when you swallow?

• 
  

  Finding:

  Confirmed use of medications

• 
  

  Finding:

  Confirms medications

  (Found)

  Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.

  Example Question:

  What medications do you take?
• 
  

  Finding:

  Reports taking a daily vitamin

  (Found)

  Pro Tip: Asking specifically about vitamin or supplement use is important, because patients don’t always consider these a “medication.”

  Example Question:

  Do you take vitamins?
• 
  

  Finding:

  Reports taking cough medicine

  (Found)

  Pro Tip: Asking specifically about medications to relieve a condition is a good way to check that a patient is remembering all of his medications Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

  Example Question:

  Are you taking medication for your cough?

• 
  

  Finding:

  Followed up on cough medicine

• 
  

  Finding:

  Reports cough medicine was purple

  (Found)

  Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices.

  Example Question:

  What color was the cough medicine?
• 
  

  Finding:

  Reports taking one spoonful of cough medicine

  (Found)

  Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices.

  Example Question:

  How much cough medicine did you take?
• 
  

  Finding:

  Reports mother gave him the medicine

  (Found)

  Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices.

  Example Question:

  Who gave you the cough medicine?
• 
  

  Finding:

  Reports cough medicine provided temporary relief

  (Available)

  Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

  Example Question:

  Did the cough medicine make you feel better?

• 
  

  Finding:

  Asked about allergies

• 
  

  Finding:

  Denies seasonal allergies

  (Found)

  Pro Tip: Seasonal allergies can cause symptoms like runny nose, cough, and discomfort. Asking Danny if he has seasonal allergies can help you to ascertain possible triggers for symptoms.

  Example Question:

  Do you have seasonal allergies?
• 
  

  Finding:

  Denies food allergies

  (Found)

  Pro Tip: Knowing if your patient has food allergies is important and relevant medical history. Asking your patient about food allergies will allow you to most effectively treat him.

  Example Question:

  Do you have food allergies?
• 
  

  Finding:

  Denies medication allergies

  (Found)

  Pro Tip: Knowing if your patient has allergies to medicine is important and relevant medical history. Asking your patient about medicine allergies will allow you to most effectively treat him.

  Example Question:

  Are you allergic to any medicine?
• 
  

  Finding:

  Denies allergies to animals

  (Available)

  Pro Tip: Asking about allergies to animals is important for a child with respiratory problems, because the issue could be caused or exacerbated by a family pet or recent exposure to an animal.

  Example Question:

  Are you allergic to animals?
• 
  

  Finding:

  Denies latex allergy

  (Available)

  Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts.

  Example Question:

  Are you allergic to latex?

• 
  

  Finding:

  Asked about relevant medical history

• 
  

  Finding:

  Denies asthma diagnosis

  (Found)

  Pro Tip: Asthma is a serious medical condition that can be life-threatening if not managed appropriately. Regardless of the patient’s presenting illness, it is critical to identify current medical conditions in order to treat the patient appropriately. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data. Specific questions should be asked about previous medical problems, even if the patient doesn’t notice current symptoms.

  Example Question:

  Do you have asthma?
• 
  

  Finding:

  Reports immunizations as current

  (Found)

  Pro Tip: A health assessment should include an evaluation of the patient’s immunization status in order to identify diseases to which the patient is vulnerable.

  Example Question:

  Do you have current immunizations?
• 
  

  Finding:

  Reports past pneumonia and frequent coughs

  (Found)

  Pro Tip: Respiratory conditions extremely limit one’s ability to function in normal life activities. It’s important to identify the patient’s health conditions in order to care for her safely and effectively. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

  Example Question:

  Do you have a history of respiratory problems?
• 
  

  Finding:

  Denies past hospitalizations

  (Available)

  Pro Tip: Asking about previous hospitalizations will give you a broader understanding of the patient’s medical history in addition to guiding your assessment of their chief complaint.

  Example Question:

  Have you ever been to the hospital?

• 
  

  Finding:

  Asked about exposure to secondhand smoke

• 
  

  Finding:

  Reports father smokes cigars

  (Found)

  Pro Tip: Secondhand smoke puts the patient at risk for many medical conditions may exacerbate breathing problems associated with a respiratory complaint. Knowing about household exposure to irritants such as smoke will help you know about potential sources of Danny’s complaint.

  Example Question:

  Who smokes at home?
• 
  

  Finding:

  Reports father sometimes forgets to take cigars outside

  (Available)

  Pro Tip: Secondhand smoke puts the patient at risk for many medical conditions may exacerbate breathing problems associated with a respiratory complaint. Knowing about household exposure to irritants such as smoke will help you know about potential sources of Danny’s complaint.

  Example Question:

  Where does your father smoke?

• 
  

  Finding:

  Asked about general symptoms

• 
  

  Finding:

  Reports frequent colds

  (Found)

  Pro Tip: Asking about the patient’s susceptibility to colds is should guide your assessment.

  Example Question:

  Do you have unusually frequent colds?
• 
  

  Finding:

  Denies fever

  (Found)

  Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has a fever will illustrate the way his symptoms manifest.

  Example Question:

  Do you have a fever?
• 
  

  Finding:

  Denies chills

  (Found)

  Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has chills will illustrate the way his symptoms manifest. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

  Example Question:

  Do you have chills?
• 
  

  Finding:

  Reports reports feeling “kind of tired”

  (Found)

  Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has fatigue will illustrate the way his symptoms manifest.

  Example Question:

  Do you have fatigue?
• 
  

  Finding:

  Denies night sweats

  (Found)

  Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has night sweats will illustrate the way his symptoms manifest.

  Example Question:

  Do you have night sweats?
• 
  

  Finding:

  Denies weight loss

  (Available)

  Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has lost weight will illustrate the way his symptoms manifest.

  Example Question:

  Have you lost weight?
• 
  

  Finding:

  Denies appetite loss

  (Available)

  Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny about his appetite will illustrate the way his symptoms manifest.

  Example Question:

  Have you lost your appetite?

• 
  

  Finding:

  Asked about review of systems for HEENT

• 
  

  Finding:

  Denies ear popping or crackling

  (Available)

  Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has any ear popping, will help you to understand his symptoms.

  Example Question:

  Do you hear any popping sounds?
• 
  

  Finding:

  Reports history of frequent ear infections

  (Available)

  Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has ear infections, will help you to understand his symptoms.

  Example Question:

  Have you ever had ear infections?
• 
  

  Finding:

  Denies ear surgery or ear tubes

  (Available)

  Pro Tip: It is important to ask your patient about past surgeries to better understand the scope of previous treatment as well as rule out possible complications that may be resulting in the patient’s condition.

  Example Question:

  Have you ever had surgery on your ears?
• 
  

  Finding:

  Denies headaches

  (Found)

  Pro Tip: Headaches are a common complaint that can be caused by a variety of benign conditions. However, headaches can be an indicator of serious underlying neurological conditions such as cerebral hemorrhage, meningitis, or brain tumors. They may also be a symptom of sinus infection.

  Example Question:

  Do you get headaches?
• 
  

  Finding:

  Denies nosebleeds

  (Found)

  Pro Tip: Infected sinuses can manifest as nose problems. Asking Danny about his nasal symptoms solicits information about his sinuses and possible sinus problems. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

  Example Question:

  Do you have nosebleeds?
• 
  

  Finding:

  Denies vision problems

  (Found)

  Pro Tip: Eye or vision problems can lower one’s ability to function and can be a major safety risk.

  Example Question:

  Do you have any problems with your vision?
• 
  

  Finding:

  Denies dizziness

  (Found)

  Pro Tip: Asking about dizziness assesses for inner ear, neurological, or cardiovascular problems.

  Example Question:

  Do you have any dizziness?
• 
  

  Finding:

  Denies watery eyes

  (Found)

  Pro Tip: Eye or vision problems can lower one’s ability to function and can be a major safety risk.

  Example Question:

  Do you have watery eyes?
• 
  

  Finding:

  Denies eye redness

  (Found)

  Pro Tip: Eye or vision problems can lower one’s ability to function and can be a major safety risk.

  Example Question:

  Do you have eye redness?
• 
  

  Finding:

  Denies eye pain

  (Found)

  Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Danny whether he is experiencing eye pain solicits information about possible symptoms.

  Example Question:

  Do you have any eye pain?
• 
  

  Finding:

  Denies sinus pain

  (Found)

  Pro Tip: Infected sinuses can manifest as nose problems. Asking Danny about his nasal symptoms solicits information about his sinuses and possible sinus problems.

  Example Question:

  Do you have any sinus pain?
• 
  

  Finding:

  Denies hearing problems

  (Found)

  Pro Tip: Asking your patient about their specific symptoms and the way that they manifest, like if he has hearing problems, will help you to understand his symptoms.

  Example Question:

  Do you have any hearing problems?

• 
  

  Finding:

  Asked about review of systems for respiratory

• 
  

  Finding:

  Denies difficulty breathing

  (Found)

  Pro Tip: It’s important to ask about episodes of shortness of breath because ineffective breathing can be life-threatening. Shortness of breath can be caused by respiratory or cardiac conditions, allergies, or exercise.

  Example Question:

  Do you have difficulty breathing?
• 
  

  Finding:

  Denies chest tightness

  (Found)

  Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest tightness is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

  Example Question:

  Do you have chest tightness?
• 
  

  Finding:

  Denies chest pain

  (Found)

  Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest pain is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort.

  Example Question:

  Do you have any chest pain?
• 
  

  Finding:

  Reports no history of inhaler use or breathing treatments

  (Available)

  Pro Tip: Respiratory conditions extremely limit one’s ability to function in normal life activities. It’s important to identify the patient’s health conditions in order to care for her safely and effectively.

  Example Question:

  Have you ever used a medicine that you inhaled?

• 
  

  Finding:

  Asked about relevant family history

• 
  

  Finding:

  Reports not being around anyone ill at home

  (Available)

  Pro Tip:

  Example Question:

  Is anyone sick at your house?
• 
  

  Finding:

  Reports father had asthma as a child

  (Found)

  Pro Tip: Medical problems that are present in a patient’s immediate family can represent increased risk factors to many medical conditions for the patient.

  Example Question:

  Do you have a family history of asthma?
• 
  

  Finding:

  Denies family history of allergies

  (Found)

  Pro Tip: Medical problems that are present in a patient’s immediate family can represent increased risk factors to many medical conditions for the patient. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data.

  Example Question:

  Do you have a family history of allergies?
• 
  

  Finding:

  Denies pets at home

• Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

**Title:** Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data

**Category: Scored Items**

**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 cough:

Reports coughing every couple minutes

Asked about character of cough:

Reports cough is wet

Reports clear sputum with cough

Asked about aggravating factors for cough:

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

Denies food allergies

Denies medication allergies

Denies allergies to animals

Denies latex allergy

Asked 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 feeling “kind of tired”

Denies night sweats

Denies weight loss

Denies appetite loss

Asked about review of systems for HEENT:

Denies ear popping or crackling

Reports history of frequent ear infections

Denies ear surgery or ear tubes

Denies headaches

Denies nosebleeds

Denies vision problems

Denies dizziness

Denies watery eyes

Denies eye redness

Denies eye pain

Denies sinus pain

Denies hearing problems

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

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