DCE lab
Instructions
Complete your documentation using the documentation template ( template below)
Included the Information in different attachment and template – Please use only the information can be equal the document
Name: Danny Rivera
Section:
Week 5
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Health Maintenance:
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Neck:
Breasts:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Psychiatric:
Neurological:
Skin:
Hematologic:
Endocrine:
Instructions
Complete your documentation using the documentation template
Included the Information in different attachment and template
© 2021 Walden University Page 1 of 1
DCE Provider Notes – Focused Exam: Cough, Danny Rivera
Subjective
Danny is an 8-year-old male patient who is brought to the clinic by Abuela with chief complaint
of coughing of cough that has lasted for five days. He reports that the cough gets worse at night
and is always kept awaken by the cough. He also reports mild throat sores. He also reports
general fatigue and takes purple-like medicine for cough, given to him by his mother. Danny also
reports pain on the right eye. He also reports she also reports that he has had frequent ear
infection, He admits pain when swallowing. Danny also reported history of pneumonia in the
past year when he was 7 years old. Danny denies chills fever, headache. He also denies cough
aggravation with activity.
Objective
General: Danny is a fatigue-looking various. Danny appears stable and in no acute distress.
HEENT: Moist membrane, clear nasal discharge. Redness, cobblestoning in the back of the
throat. Eyes: Appear dull, pink conjunctiva. Right tympanic sired and inflated. Right cervical
lymph node enlarged with reported tenderness.
Cardiovascular: S2, and S2 present, np murmurs, no gallops or rubs.
Respiratory: Rate increase without acute distress, can speak in full sentences. Breath sounds
clear to auscultations. Negative bronophony. Chest wall resonant to percussion. Expected
fremitus equal bilaterally. Spirometer readings are FVC 1.78L, FEV1 1.549L (fev1.evc: 87%).
Assessment
Main diagnosis: Cough
Differential Diagnosis: Strep, cold, rhinitis, and asthma based on the abnormal findings that
affect the es, upper respiratory track and lymph nodes.
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Plan
Refer Danny for an allergy test to rule out allergies and a lung test to rule put asthma.
Again, refer to Danny to a strep culture to rule out asthma.
Administer antitussive treatment to Danny at night to help him sleep with bed rest.
This study source was downloaded by 100000830998373 from CourseHero.com on 03-27-2022 15:57:29 GMT -05:00
https://www.coursehero.com/file/96371262/DCE-Provider-Notes-Focused-Exam-Cough-Danny-Riveradocx/
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