NUR 634 Shadow Health Assignment; Focused Exam; Cough
- $25.00
Chief complaint
“I have been coughing a lot and feel tired” History of Presenting Illness
Danny Rivera is an 8 y/o, Puerto Rican American boy with a history of pneumonia last year presenting to the clinic complaining of a cough. His grandma brought him in to the clinic because she is concerned about his cough. He reports that the cough started five days ago. His mom gave him cough medicine that made his cough a little better, but he states it gets worse at night. He rates his cough a 5/10 and reports it being gurgled and watery without any radiating pain. He notices that he is coughing every couple of minutes. He repots fatigue due to lack of sleep from his cough keeping him up at night. He reports a mild sore throat and some pain in his right ear since yesterday. He reports frequent ear infections as a child. He denies fever and difficulty breathing. He denies coming in contact with anyone else who is sick.
Medical History
Pneumonia: Diagnosed at 7 y/o. Treated at urgent care. Surgical History
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Mother: In her 30’s. History of type two diabetes, hypertension, hypercholesterolemia, spinal stenosis, and obesity
Father: In his 30’s. Current smoker with a history of hypertension, hypercholesterolemia, and asthma as a child.
Paternal Grandfather: No known medical history.
Paternal Grandmother: Passed away due a car accident at 52 y/o. No known medical history. Maternal Grandfather: History of smoking and eczema.
Maternal Grandmother: History of diabetes and hypertension. Social History:
Danny is a pleasant 3rd grader who was born in Shadowville. He has a great attendance record at school and only missed 2 weeks last year when he had pneumonia. He lives with his mom, dad, and grandparents, and when his parents are at work, his grandparents take care of him. His mom is a stenographer at the courthouse and his dad works as a security officer at the courthouse as well. He primarily speaks English, but some Spanish is spoken in the household. He describes himself as pretty healthy and saw his primary care doctor a couple months ago. He reports eating healthy and isn’t allowed much junk food and his family is always encouraging him to drink lots of water. He normally gets about eight hours of sleep each night but has been having a harder time sleeping lately due to the cough. His dad smokes cigars and he reports his parents will drink a beer every now and then. He states he is safe at home. He is fully up to date on his necessary
childhood immunizations but is due for his influenza vaccine for this season. He enjoys hanging out with his best friend, Tony, playing video games, reading, and writing stories........... Continue
