Nurs 6512n Advanced Health Assessment & Diagnostic Reasoning ; Episodic Focused Note For Focused Exam Cough

NURS - 6512N: Advanced Health Assessment & Diagnostic Reasoning Episodic/Focused Note for Focused Exam: Cough Patient Name: Daniel Rivera Age: 8 Gender: Male SUBJECTIVE DATA: Chief Complaint (CC): " I have been coughing a lot." History of Present Illness (HPI): Danny is a 8-years-old-boy. He states coughing started 5 days ago. Coughs with clear sputum. Reports sore throat and running nose with clear, thin discharge. Reports right ear hurting since yesterday, rated as 3/10 on the pain scale. Denies fever. Mom gives coughing medicine to relieve the symptom. Reports feeling tired at times. Sleep disturbances by overnight coughing. Denies breathing problem or asthma. Current Medications: 1. OTC cough medicine (name unknown). one spoon given. 2. Daily multivitamin (Gummy Bears - name unknown) Allergies: Denies any food allergy. Denies any medication allergy. Denies seasonal allergy. Denies allergic to any animals. Past Medical History: No surgical history reported No prior hospitalizations reported Pneumonia (last year), treated at urgent care. Social History: Danny, is a 3rd grader and he is the only child in the family. He lives with his mother, father (Security officer), and grandmother. Grandmother provides care when parents are working. Danny enjoys reading, writing, and his best friend is Tony.