Danny Rivera Pediatric Cough Shadow Health Assessment Documentation

Danny Rivera Pediatric Cough Shadow Health Assessment Documentation

Documentation / Electronic Health Record

Document: Vitals

Document: Provider Notes

Document: Vitals

Vitals

Blood Pressure

120/76

O2 Sat

96

Pulse

100

Resp. Rate

28

Temperature

37.2C

Documentation / Electronic Health Record

Document: Vitals

Document: Provider Notes

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Document: Provider Notes

Student Documentation

Model Documentation

Subjective

Danny Rivera is an 8 year old male patient who reports to have had a cough for the last 4 to 5 days. He reports the cough is worse at night and makes him not sleep well and also gets fatigued. He describes the cough as watery. He also has a running nose. He has mild soreness in his throat which he relieves with over the counter drugs. He had ear infections when young and had pneumonia in the past. He denies any headache, dizziness, fever, sputum, chest pain, , abdominal pain or breathing problems. His cough does not get worse when he is active.

Return to Canvas to complete your SOAP note for this assignment. Danny Rivera Pediatric Cough Shadow Health Assessment Documentation

Objective

HEET: Mucus membranes are moist, with a clear nasal discharge. Redness, cobblestoning at the back of the throat. Eyes are dull with pink conjuctiva. Right tympanic memebrane is inflamed . It is also red. The right cervical lymph node is tender and enlarged. Cardiovasicular: S1, S2. There is neither murmurs, gallops nor rubs. Respiratory: Respiratory rate is increased but no distress. Breath sounds are clear to auscultation and negative bronchophony. The chest wall is resonant to percusion. Spirom… Danny Rivera Pediatric Cough Shadow Health Assessment Documentation