Student Response Model Documentation Subjective Chief complaint patient states he has been coughing and feeling tired recently. Patient states the cough started 5 days ago. Patient states the cough is intermittent in nature. Patient states he has been producing clear colored sputum. Patient states cough is worse at night. Patient denies relieving factors. Patient states his mother has been giving him over-the-counter cough medicine but the cough has persisted. Current medications include daily multivitamins and patient is also taking over the counter cough medicine Allergies patient denies allergies Past medical history includes pneumonia diagnosed at age 7. Patient has not had the influenza vaccine this year Hepatitis B 3 dose series completed at 6 months hepatitis A two dose series completed at 15 months pneumococcal for dose series completed at 15 months. DTaP V dose series completed at 6 years MMR two dose series completed at 6 years varicella two dose series completed at 6 years polio 4- dose series completed at 6 years Social history patient states he is in the third grade he plays video games or reads or writes stories for fun if his friend Tony is available they will play together. Patient denies use of tobacco and alcohol products. Patient states he uses a seatbelt when in a car. Family history: mother suffers from type 2 diabetes, hypertension, hypercholesterolemia, spinal stenosis, obesity. Father is a smoker suffers from hypertension hypercholesterolemia, Asthma as a child. Maternal grandmother type 2 diabetes and hypertension maternal grandfather is smoker and suffers from eczema Paternal grandmother died in the car accident at age 52 years old paternal grandfather no known history.
- Fall '15
- Grandparent, cough, Common cold