Focused Exam: Cough

Nursing Documentation

Subjective Data

Chief complaint: “watery and ‘gurgly’ cough.”

Focused Exam: Cough

History of Presenting Illness: Danny Riviera is an 8-year-old Hispanic male child who presented for evaluation due to 3-day history of cough. The cough is productive, and he described the sputum as slimy and clear. Each cough episode lasts a ‘couple of seconds and is preceded by a feeling of throat irritation and an urge to cough. The cough is worse at night, and this gives him trouble staying asleep. The cough is associated with mild soreness in the throat, warry nasal discharge, and fatigue.

The patient denies changes in his hearing, pain in his ears, discharge from the ears, or cheek pain. He also denied vision changes or dizziness. His grandmother has been giving him Dimetapp formula regularly and chest rub before sleep, but these interventions have not shown symptomatic improvement. Danny reports that his friend also has a similar cough and water nasal discharge symptoms. He reports positive contact with this friend a few days ago. His grandmother reports that Danny’s temperature has been normal.

Past Medical History: the patient was diagnosed with pneumonia last year. He also reports that he has been frequently diagnosed with otitis media, but there have been no symptoms recently. He has no diabetes, epilepsy, asthma, or known chronic condition.

Allergies: he denies any food or medication allergies. He also has no allergies.

Current medications: he currently takes a daily multivitamin but reports taking more than the prescribed dose because it is sweet. Danny understands that he should only take the required dose of daily multivitamins.

Family History: the patient reports exposure to secondhand smoke because his father smokes in the house. His father has hypertension, hyperlipidemia, and childhood asthma. His mother also has hypertension, type 2 diabetes mellitus, and hyperlipidemia. No other known chronic inheritable conditions are reported in the family.

Social history: the patient has infrequent hand hygiene during the day. He verbalizes an understanding of the importance of regular handwashing to prevent contracting germs. He also reports touching his face often.

Review of Systems

General: no fever, weight loss, or night sweats

Head: no headache or history of recent injury

Eyes: no blurry vision, excessive tearing, redness, pain, or abnormal discharge

Ears: no pain, discharge, or reduced hearing

Nose: history of clear watery rhinorrhea but no purulent discharge, bleeding, or congestion

Throat: soreness in the throat but no pain or difficulty during swallowing

Respiratory: history of productive cough but no shortness of breath, chest pain, or chest tightness

Cardiovascular: no heartbeat awareness, left-sided chest pain, orthopnea, syncope, or leg swelling.

Gastrointestinal: no nausea, vomiting, burping, diarrhea, constipation, abdominal pain, yellowing of eyes, or blood in stool

Neurological: no confusion, numbness, paralysis, tingling sensations, weakness, or convulsions

Musculoskeletal: no muscle pain, weakness,  joint pain, joint swelling, deformities, or weakness

Hematological: no easy bruising, bleeding, or history of anemia

Lymphatic: no leg swelling or pain

Psychiatric: no depression, anxiety, or behavioral problems were reported

Objective data

General: the patient is in good condition without signs of respiratory distress or anxiety. Maintains eye contact and interacts positively with the examiner.

Vital signs:

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SpO2 =

Weight =

Height =

BM =

Physical Examination:

Eyes: the orbital area has no abnormal findings. Both sclerae are white, and the conjunctiva pink and moist with no discharges.

Nose and Sinuses: the nasal cavity is pink with no discharge. The turbinate is patent with no abnormal findings. Frontal and maxillary sinuses are not tender on palpation.

Ear: the external auditory canals are pink and clear with no excess cerumen impaction. The tympanic membranes are pearly grey. The cone of light is not distorted in both ears and is at 7 am for the right ear and 5 am for the right ear. The tympanic membranes are not bulging and have no scars, perforation, or retraction in both ears.

Mouth and throat: The oral mucosa is moist and pink with no swelling, redness, or ulcers. The throat is erythematous and has cobble-stoning. There is no postnatal discharge.

Neck: the neck is symmetrical and has visible masses, visible pulsation, stiffness, or discoloration

Chest: the chest is symmetric and has no barreling, intercostal or subcostal retraction, rash, or skin moles. The breath sounds are present in all lung fields, and there are no adventitious sounds (wheezes, crackles, stridor, rhonchi, or rales). Palpable tactile fremitus is present and equal bilaterally. Chest expansion is equal bilaterally. Bronchophony is negative

Cardiovascular: S1 and S2 are audible on auscultation, and there are no murmurs, gallops, friction rubs, or valve clicks. There are no areas of dullness to percussion. All lung fields are resonant.

Lymph nodes: axillary, cervical, supraclavicular, submandibular, submental, sublingual, and preauricular nodes are not palpable bilaterally.

Assessment

Nursing diagnosis: risk of infection as evidenced by playing with a sick friend, rare handwashing, touching the face often, and exposure to secondhand smoke. The rationale is that this patient has not developed symptoms of infection, but relevant behavior in history suggests the risk. The patient has a cough, rhinorrhea, and sore throat that could be suggestive of an upper respiratory tract infection (URTI).

According to (Barrett, 2018), cough, sore throat, and rhinorrhea are some of the most common symptoms of upper respiratory tract infection. According to Tang et al. (2019), viruses are the most common cause of acute respiratory infections. A narrative review by Jiang et al. (2020) reported that smoking is a risk factor for upper respiratory infection. This patient was exposed to secondhand smoke from the father’s smoking.

Differential diagnoses

COVID-19: This highly infectious respiratory infection could be a possibility in this patient because of important positives that include positive contact with a patient with similar symptoms, cough, sore throat, and rhinorrhea. Important negatives include the absence of facial pain and pressure and no purulent discharge that would suggest bacterial infection. The absence of fever can rule out this differential.

Common cold: This is the most common reason for outpatient visits in most settings. Rhinorrhea, sore throat, cough, and nasal stuffiness are some common symptoms (Barrett, 2018). Positive contact suggests infection due to airborne means in this patient. Viral causes are possible causes in this patient.

Flu: In some ways, it presents similarly to the common cold. Influenza virus is the most common etiology. Acute rhinorrhea, cough, and sore throat are always present (Barrett, 2018). The patient’s flu shot history is unavailable; thus, need to rule out the flu as a cause.

Acute pharyngitis: this illness occurs mostly from bacterial and viral etiologies. Sore throat and cobblestones in this patient highly suggest acute pharyngitis.

Plan

Patient education on handwashing hygiene is important for this patient to reduce risk factors and prevent infections. The patient and the grandmother should understand their risks and need for preventive strategies such as handwashing and avoidance of touching of face and mouth. Avoidance of secondhand smoke is also essential in this patient. The patient has a previous history of infections this a need to prevent further infection and complications. These preventive strategies can reduce the risk of transmitting the infection to others.

The outcomes are that the patient will verbalize understanding of the educational instruction. The ability of the patient and his grandmother to verbalize correct preventive strategies as taught in the patient education will be used to measure the outcome. The rationale for this intervention is that patient education can ensure infection prevention through the health belief model. The health belief model explains that enhancing patient self-efficacy, perceived threats, and perceived benefits can improve their willingness and ability to take action to prevent illness.

References

Barrett, B. (2018). Viral Upper Respiratory Infection. In Integrative Medicine (pp. 170-179.e7). Elsevier.

Huang, Y., Hua, J., Wang, D., Chen, L., Zhang, J., Zhu, H., Tian, J., Zhang, T., & Zhao, G. (2018). Risk factors of respiratory syncytial virus infection among pediatric influenza-like illness and severe acute respiratory infections in Suzhou, China. Journal of Medical Virology90(3), 397–404. https://doi.org/10.1002/jmv.24961

Jiang, C., Chen, Q., & Xie, M. (2020). Smoking increases the risk of infectious diseases: A narrative review. Tobacco Induced Diseases18(July), 60. https://doi.org/10.18332/tid/123845

Tang, J., Chen, J., He, T., Jiang, Z., Zhou, J., Hu, B., & Yang, S. (2019). Diversity of upper respiratory tract infections and prevalence of Streptococcus pneumoniae colonization among patients with fever and flu-like symptoms. BMC Infectious Diseases19(1), 24. https://doi.org/10.1186/s12879-018-3662-z

Focused Exam: Cough Subjective Data Collection: 21 of 21 (100.0%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

Finding:

Established chief complaint

Finding:

Reports cough

(Found)

Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

Do you have a cough?

History of Present Illness

Finding:

Asked about onset of cough

Finding:

Reports cough started 5 days ago

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How long have you had a cough?

Finding:

Asked about frequency and duration of cough

Finding:

Reports coughing every few minutes

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How frequently have you been coughing?

Finding:

Asked about character of cough

Finding:

Reports cough is wet

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is your cough a wet cough?

Finding:

Reports clear sputum

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you produce any phlegm or sputum with your cough?

Finding:

Asked about aggravating factors for cough

Finding:

Reports cough is worse at night

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is your cough worse at night?

Finding:

Reports exposure to secondhand smoke

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Are you around anyone who smokes at home?

Finding:

Denies knowing what makes the cough worse

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

What makes your cough worse?

Finding:

Asked about relieving factors for cough

Finding:

Denies resting relieves cough

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does resting help your cough?

Finding:

Denies drinking water relieves cough

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does drinking water help your cough?

Finding:

Asked about nasal symptoms

Finding:

Reports current runny nose

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have a runny nose?

Finding:

Denies sneezing

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Have you been sneezing?

Finding:

Reports frequent runny nose

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you get runny noses often?

Finding:

Followed up on nasal discharge

Finding:

Reports nasal discharge is clear

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

What color is your snot?

Finding:

Reports nasal discharge is thin

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is your snot thin?

Finding:

Asked about ear symptoms

Finding:

Reports pain in right ear

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have any ear pain?

Finding:

Followed up on ear pain

Finding:

Reports ear pain started yesterday

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How long have you had ear pain?

Finding:

Reports ear pain is a 3 out of 10

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Can you rate your ear pain on a scale?

Finding:

Denies ear discharge

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have any ear discharge?

Finding:

Asked about throat symptoms

Finding:

Reports sore throat

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is your throat sore?

Finding:

Reports “a little” pain with swallowing

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does it hurt when you swallow?

Finding:

Asked about allergies

Finding:

Denies seasonal allergies

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have seasonal allergies?

Finding:

Denies food allergies

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have food allergies?

Finding:

Denies medication allergies

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Are you allergic to any medicine?

Finding:

Denies allergies to animals

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Are you allergic to animals?

Finding:

Denies latex allergy

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Are you allergic to latex?

Finding:

Asked about contact with illnesses

Finding:

Denies being around anyone ill at home

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is anyone sick at home?

Home Medications

Finding:

Asked about home medications

Finding:

Confirmed home medications

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What medications do you take?

Finding:

Reports taking a daily vitamin

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you take vitamins?

Finding:

Reports taking cough medicine

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Are you taking medication for your cough?

Finding:

Followed up on cough medicine

Finding:

Reports cough medicine was purple

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What color was the cough medicine?

Finding:

Reports taking one spoonful of cough medicine

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How much cough medicine did you take?

Finding:

Reports mother gave him the medicine

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Who gave you the cough medicine?

Finding:

Reports cough medicine provided temporary relief

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Did the cough medicine make you feel better?

Past Medical History

Finding:

Asked about relevant medical history

Finding:

Denies asthma diagnosis

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have asthma?

Finding:

Reports immunizations as current

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have current immunizations?

Finding:

Reports past pneumonia and frequent coughs

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have a history of respiratory problems?

Finding:

Denies past hospitalizations

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Have you ever been to the hospital?

Social Determinants of Health

Finding:

Asked about exposure to secondhand smoke

Finding:

Reports father smokes cigars

(Found)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

Who smokes at home?

Finding:

Reports father sometimes forgets to take cigars outside

(Available)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

Where does your father smoke?

Social History

Finding:

Asked about living conditions

Finding:

Reports living in a house with parents and grandparents

(Found)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Where do you live?

Finding:

Reports feeling safe at home

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Do you feel safe at home?

Finding:

Reports park with playground near home

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Is there anywhere near your home where you can play outside?

Review of Systems

Finding:

Asked about constitutional health

Finding:

Denies fever

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have a fever?

Finding:

Denies chills

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have chills?

Finding:

Reports feeling “kind of tired”

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have fatigue?

Finding:

Denies night sweats

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have night sweats?

Finding:

Denies weight loss

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Has your weight changed?

Finding:

Denies appetite loss

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Have you lost your appetite?

Finding:

Asked about review of systems for HEENT

Finding:

Denies ear popping or crackling

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you hear any popping sounds?

Finding:

Reports history of frequent ear infections

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Have you ever had ear infections?

Finding:

Denies ear surgery or ear tubes

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Have you ever had surgery on your ears?

Finding:

Denies headaches

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you get headaches?

Finding:

Denies nosebleeds

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have nosebleeds?

Finding:

Denies vision problems

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any problems with your vision?

Finding:

Denies dizziness

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any dizziness?

Finding:

Denies watery eyes

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have watery eyes?

Finding:

Denies eye redness

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have eye redness?

Finding:

Denies eye pain

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any eye pain?

Finding:

Denies sinus pain

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any sinus pain?

Finding:

Denies hearing problems

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any hearing problems?

Finding:

Asked about review of systems for respiratory

Finding:

Denies difficulty breathing

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have difficulty breathing?

Finding:

Denies chest tightness

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have chest tightness?

Finding:

Denies chest pain

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any chest pain?

Finding:

Denies history of inhaler use or breathing treatments

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Have you ever used an inhaler?

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