Danny Rivera Focused Note Sample Paper
Danny Rivera Focused Note
Date of encounter: 22/AUG/2018
Patient Name or initials: Danny Rivera
Informant: Informant is the patient, an 8-year-old Hispanic-American male.
Chief Complaint (CC): “Been feeling sick. I have been coughing a lot. Feeling kind of tired.”
History of present illness (HPI): Patient presents with a cough that started five days ago. Reports his cough worse at night. Reports fatigue because “Coughing keeps him up at night.” Describes cough as productive and “gurgly and watery.” Reports clear sputum. Reports severity 5/10, and frequency is every few minutes. States cough “Stays the same” with activity. Denies chest pain or difficulty breathing. Reports pain to right ear with a 3/10 pain.
Reports sore throat, pain of 2/10. No difficulty swallowing. Reports runny nose, clear drainage. Denies being around illness. No recent fever. Denies similar symptoms to pneumonia. Mother gave cough medicine once in am, offered some relief. He reports normal bowel movements. He denies headache, dizziness, nosebleed, phlegm, or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity.
Allergies: No known drug, or food allergies noted.
Medications: Patient takes a daily multivitamin and an OTC cough suppressant.
Past History: No past surgical history, or prior hospitalizations noted. Childhood illness reported: Chickenpox at age 6. Patient was treated at an Urgent Care Clinic last year for Pneumonia. Patient acknowledges a history of recurrent ear infections at younger age.
Family History: Mother: diabetes, high cholesterol, HTN. Father: HTN, high cholesterol, smoker, asthma as a child. Maternal grandmother: Smoker, eczema. Paternal grandmother: Died in a car accident (52 years old). Paternal grandfather: No known history.
Personal and Social History: Patient is currently in the 3rd grade, likes school and gets good grades. Best friend is Tony. Doesn’t play any sports, but does some psychical active with friends. Patient was out for two weeks last year due to pneumonia. He lives with his mother and father, and his grandmother provides care while his parents work. Enjoys video games. No animals in the house. Denies recent travel. Patient notes some exposure to smoking when father smokes in the house.
Health Promotion/Maintenance Activities: Immunizations are up to date; no influenza vaccination noted this past year.
Pertinent Review of systems (ROS):
General: Patient notes increased fatigue due to poor sleep. No change in appetite or activities.
Skin: No rashes. No skin changes.
Eyes: Reports good vision.
Ears: See HPI. Patient reports good hearing. No tinnitus or vertigo.
Nose: Reports nose is often runny. Increase rhinorrhea presently.
Throat: See HPI. Report good dental hygiene.
Neck: No changes or swelling.
Respiratory: No history of asthma. Denies shortness of breath, wheezing.
CV/PV: Denies chest pain.
GI: Denies nausea, vomiting. Denies bowel issues.
GU: Denies urinary issues and nocturnal enuresis.
Neuro: Patient notes no headaches, trauma, or periods of confusion.
- Have you been around any other sick individuals prior to the presentation of your symptoms?
- Do you practice good hand hygiene throughout the day?
- Do you share food and drink with other kids at school?
BP: 120/76 (91)
Pulse Ox: 96%
Ht. 127cm, Wt. 40.8kg
Constitutional/General survey: Fatigued appearing young boy seated on nursing station bench. Appears stable.
HEENT: Mucus membranes are moist, clear nasal discharge. Redness, and cobblestoning noted in the back of throat on exam. Eyes are dull in appearance, pink conjunctiva. Right Tympanic membrane is red and inflamed.
Lymph nodes: Right cervical lymph node enlarged with reported tenderness.
CV: S1, S2, no murmurs, gallops or rubs.
Respiratory: Respiratory rate increased, but no acute distress. Patient is able to speak in full sentences. Breath sounds clear to auscultation. Negative bronchophony. Chest wall is resonant to percussion on exam. Expected fremitus noted, and equal bilaterally.
Spirometry: FEV1: 3.15 L, FVC 3.91 L (FEV1/FVC: 80.5%).
Neurological: Patient is AAOx3, and PERRLA, +3 and brisk bilaterally.
- Upper Respiratory Infection (cold)
- Otitis Media
- Acute Bronchitis
- Strep throat.
The differentials are based on abnormal findings affecting the ears, upper respiratory tract and lymphatic regions. Danny Rivera Focused Note Sample Paper
Opaque tympanic membrane of right ear
Danny Rivera Focused Note Example 2
|Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. When you are ready to submit your documentation, ‘Save As’ with this title format: “[LastName_FirstName] Shadow Health Documentation Template – FE_Cough – NURS 6512”|
Focused Exam: Cough
|Daniel “Danny” Rivera is an 8-year-old male presenting to the clinic with a cough. He is accompanied to the clinic by his maternal grandfather. He reports that the cough began 5 days ago. He describes the cough as “watery and gurgly” and clear in color. He reports that the cough worsens at night thus keeping him awake. He reports feeling generally tired, which is associated with his lack of sleep. Danny reports that his mother treated the cough with over-the-counter medicine, which he describes as “purple” in color.
Reports the medicine being mildly effective. He reports having mild soreness in his throat and mild pain when swallowing, associated with the cough. He reports that his nose is always a bit runny but has been worse since the onset of the cough. He also reports current pain in the right ear and reports a history of frequent ear infections. He reports contracting pneumonia last year. He however denies current headaches, fever, dizziness, or eye problems. No chest pain, nose bleeding, trouble breathing or trouble swallowing. He states he can still run and play.
|General Survey: A young boy, appearing fatigued, seated upright on the examination table. His condition appears stable.
Eyes: Sclera is white bilaterally, conjunctiva is moist and pink bilaterally, no conjunctival drainage. No visible abnormal findings.
Nose: Nasal cavities bilaterally pink and patent. Clear nasal discharge observed.
Ear: Bilateral auditory canals pink. Bilateral TMs pearly gray. No discharge. Right TM cone of light 5, left TM cone of light 7.
Mouth: Oral mucosa moist and pink. Throat red with visible cobblestoning. No post-nasal drip observed.
Neck: Symmetric. No visible abnormal findings.
Cardiovascular: S1, S2 present. Mild tachycardia. Murmurs, gallops absent. Chest is resonant with no areas of dullness. Expected fremitus, equal bilaterally on palpation. Breath sounds present in all areas. No adventitious sounds present. Bronchophony is negative.
Respiratory: Increased respiratory rate, but patient is in no acute distress. Breath sounds clear on auscultation.
|8-year-old male of Hispanic American descent presenting to the clinic with a 5-day history of cough, sore throat, fatigue and right ear pain. The onset and presentation of symptoms indicate a likely upper respiratory tract infection. The presence of clear sputum and the absence of audible adventitious breath sounds on auscultation rules out acute bronchitis.
The absence of fever, onset of symptoms and a lack of post-nasal discharge eliminates Strep throat. Allergic reaction unlikely since the cough seems to worsen at night, and no reported alleviating or aggravating factors. Asthma is also unlikely due to absence of wheezing, no dyspnea, constant cough. Further, the absence of fever, lack of adventitious breath sounds, and stable vital signs help rule out pneumonia.
Diagnosis: Upper Respiratory Infection
Diagnostics: CBC to assess WBC. Order chest x-ray to rule out pneumonia. Order Strep culture to help rule out strep throat.
Pharmacology: Prescribe Robitussin 10 ml PO every six hours for cough relief.
Education and Counselling: Educate the family on effective medication use.
Health promotion: Advise the patient to increase water or fluid intake and to get more rest time. Educate the patient and family on signs to look out for in case of worsening symptoms. Advise immediate ED visit should the patient exhibit increased shortness of breath, wheezing, chills, or high fever.
Referral: Refer the patient to a allergist to help rule out allergic reactions.
Follow-up care: Call the patient to schedule appointment should there be no improvement in 48-72 hours.