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DANNY RIVERA COUGH ASSESSMENT

SBAR
Danny Rivera is an 8-year-old boy presenting with a wet cough. He reports that the cough has lasted three days. He describes the cough as wet and “gurgly.”

The cough is temporarily treated by the children’s cough medicine his mother gave him; he reports that the cough is not aggravated by activity. He says the cough gets worse at night, which keeps him up. He reports tenderness in his throat. He reports a history of frequent rhinorrhea and cough. Risk factors include second-hand smoke from father, history of pneumonia in the past year, and being overweight for his age.

He has no acute respiratory distress; his lungs are clear to auscultation and is afebrile. He has current rhinorrhea; examination of the nose reveals boggy turbinate. His throat appears red with visible cobblestoning in the back. His respiratory rate is increased, and he presents mild tachycardia.

I recommend calling his grandmother to arrange for someone to pick him up from school. He should see his primary care provider within the next few days for an evaluation and tests to rule out asthma or allergies. In the meantime, he should be allowed to rest and should be given cough medicine as needed.

Objective Data collection:
Inspected eyes and orbital area :
Orbital area: no visible abnormal findings
Sclera: white
Conjunctiva : moist and pink
Conjunctival discharge : no discharge
Inspected Nasal cavities:
Color: pink
Turbinate patency :patent
Discharge: clear discharge
Observations: no additional visible abnormal findings
Inspected ears :
Right: auditory canal color: pink
Right: tympanic membrane appearance: no visible abnormal findings
Right: Discharge: no discharge
Right tympanic membrane color: pearly gray
Left: tympanic membrane color :pearly gray
Right: cone of light : 5.0
Left auditory canal color :pink

Left: tympanic membrane appearance :no visible abnormal findings
Left: cone of light :7.0
Left: Discharge: no discharge
Inspected Mouth and throat :
Oral mucosa : moist and pink
Throats color : red
Post nasal drip : no discharge
Tonsils : no visible abnormal findings
Throat texture :cobblestoning
Inspected neck :
Symmetry: symmetric
Appearance: no visible abnormal findings

Description

SBAR
Danny Rivera is an 8-year-old boy presenting with a wet cough. He reports that the cough has lasted three days. He describes the cough as wet and “gurgly.”

The cough is temporarily treated by the children’s cough medicine his mother gave him; he reports that the cough is not aggravated by activity. He says the cough gets worse at night, which keeps him up. He reports tenderness in his throat. He reports a history of frequent rhinorrhea and cough. Risk factors include second-hand smoke from father, history of pneumonia in the past year, and being overweight for his age.

He has no acute respiratory distress; his lungs are clear to auscultation and is afebrile. He has current rhinorrhea; examination of the nose reveals boggy turbinate. His throat appears red with visible cobblestoning in the back. His respiratory rate is increased, and he presents mild tachycardia.

I recommend calling his grandmother to arrange for someone to pick him up from school. He should see his primary care provider within the next few days for an evaluation and tests to rule out asthma or allergies. In the meantime, he should be allowed to rest and should be given cough medicine as needed.

Objective Data collection:
Inspected eyes and orbital area :
Orbital area: no visible abnormal findings
Sclera: white
Conjunctiva : moist and pink
Conjunctival discharge : no discharge
Inspected Nasal cavities:
Color: pink
Turbinate patency :patent
Discharge: clear discharge
Observations: no additional visible abnormal findings
Inspected ears :
Right: auditory canal color: pink
Right: tympanic membrane appearance: no visible abnormal findings
Right: Discharge: no discharge
Right tympanic membrane color: pearly gray
Left: tympanic membrane color :pearly gray
Right: cone of light : 5.0
Left auditory canal color :pink

Left: tympanic membrane appearance :no visible abnormal findings
Left: cone of light :7.0
Left: Discharge: no discharge
Inspected Mouth and throat :
Oral mucosa : moist and pink
Throats color : red
Post nasal drip : no discharge
Tonsils : no visible abnormal findings
Throat texture :cobblestoning
Inspected neck :
Symmetry: symmetric
Appearance: no visible abnormal findings

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SBAR
Danny Rivera is an 8-year-old boy presenting with a wet cough. He reports that the cough has lasted three days. He describes the cough as wet and “gurgly.”

The cough is temporarily treated by the children’s cough medicine his mother gave him; he reports that the cough is not aggravated by activity. He says the cough gets worse at night, which keeps him up. He reports tenderness in his throat. He reports a history of frequent rhinorrhea and cough. Risk factors include second-hand smoke from father, history of pneumonia in the past year, and being overweight for his age.

He has no acute respiratory distress; his lungs are clear to auscultation and is afebrile. He has current rhinorrhea; examination of the nose reveals boggy turbinate. His throat appears red with visible cobblestoning in the back. His respiratory rate is increased, and he presents mild tachycardia.

I recommend calling his grandmother to arrange for someone to pick him up from school. He should see his primary care provider within the next few days for an evaluation and tests to rule out asthma or allergies. In the meantime, he should be allowed to rest and should be given cough medicine as needed.

Objective Data collection:
Inspected eyes and orbital area :
Orbital area: no visible abnormal findings
Sclera: white
Conjunctiva : moist and pink
Conjunctival discharge : no discharge
Inspected Nasal cavities:
Color: pink
Turbinate patency :patent
Discharge: clear discharge
Observations: no additional visible abnormal findings
Inspected ears :
Right: auditory canal color: pink
Right: tympanic membrane appearance: no visible abnormal findings
Right: Discharge: no discharge
Right tympanic membrane color: pearly gray
Left: tympanic membrane color :pearly gray
Right: cone of light : 5.0
Left auditory canal color :pink

Left: tympanic membrane appearance :no visible abnormal findings
Left: cone of light :7.0
Left: Discharge: no discharge
Inspected Mouth and throat :
Oral mucosa : moist and pink
Throats color : red
Post nasal drip : no discharge
Tonsils : no visible abnormal findings
Throat texture :cobblestoning
Inspected neck :
Symmetry: symmetric
Appearance: no visible abnormal findings