![]() Denies dizziness, loss of consciousness, or vision changes. Psychiatric: No depression, anxiety, or history of psychotic disorders. His chest wall was resonant when percussed while the fremitus was expected and equal bilaterally.Ĭardiovascular/Peripheral Vascular: No chest pain, chest tightness, palpitations, edema, cyanosis, dyspnea. Respiratory: Lacks acute distress, increased respiratory rate at 28, breath sounds are clear to auscultation, speaks in full sentences while the bronchoscopy is negative. The patient’s right cervical lymph nodes appear enlarged with a certain tenderness. The right tympanic membrane appears red and inflamed. His eyes are dull while the conjunctiva is pink in color. HEENT: The mucus membrane is moist nasal discharge is clear, while he shows redness and clobbestoning at the back of his throat. Denies fever, appetite loss, weight loss, chills, or night sweats. General: The patient looks fatigued and also coughs whilst having the interview. ![]() Reports father with a history of asthma as a child. Significant Family History: He has a father, mother, and both grandparents. Immunization History: Immunizations are current. Personal/Social History: Reports living in a house with his parents and grandparents. Sexual/Reproductive History: No history of reproductive disorders. Past Surgical History (PSH): None reported. Reports past frequent coughs and pneumonia. Past Medical History (PMH): Denies asthma diagnosis. ![]() ![]() Medications: The patient admits to taking home medications. However, he does not have a fever, breathing difficulties, abdominal pain, and chest tightness and chills. He has also suffered pneumonia in the past year. He is also exposed to secondhand smoke from his father. Danny states that he suffers from a frequent runny nose as well as a cold and sore throat. His mother decided to use over-the-counter cough medicine, which offered temporal relief. NURS 6512 Week 5 Assignment 2 Digital Clinical Experience Focused Exam CoughĪnd suffers from fatigue. ![]()
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