Focused Exam- Cough |Transcript .pdf - Focused Exam Cough | Completed | Shadow Health Focused Exam Cough Results | Turned In Advanced Health Assessment

Focused Exam- Cough |Transcript .pdf - Focused Exam Cough |...

This preview shows page 1 out of 21 pages.

You've reached the end of your free preview.

Want to read all 21 pages?

Unformatted text preview: 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Focused Exam: Cough Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: Jun 04, 2018 | Patient Exam Time: 86 min All Lines (180) Interview Questions (76) Statements (8) Exam Actions (96) Objective Data Collection Education & Empathy Hello, My name is Sara an FNP student and I will be interviewing you today Documentation Self-Reflection Greet 06/04/18 2:50 PM CDT Hi. What brought you into the clinic today? Question 06/04/18 2:51 PM CDT My Abuela brought me here because I've been feeling sick. I have been coughing a lot. . . and I feel kinda tired. What is your name? Question 06/04/18 2:52 PM CDT My name is Daniel Rivera, but I just go by Danny. And how old are you? Question 06/04/18 2:52 PM CDT I'm eight. What is your date of birth? Question 06/04/18 2:52 PM CDT I was born March 4th in, um . . . [Danny reports correct birth year.] [AUDIO COMING SOON] 1/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health I'm sorry you feel so bad Empathize 06/04/18 2:54 PM CDT Thank you. When did your cough start? Question 06/04/18 2:55 PM CDT I think the cough started four. . . No, it started five days ago. Can you describe your place to me? Question 06/04/18 2:55 PM CDT My cough seems kind of gurgly and watery. Do you have any sputum? Question 06/04/18 2:56 PM CDT Is that the gross, slimy stuff? Yeah, I've been coughing some of that up. It's not any strange color, though. It's just clear. How often are you coughing? Question 06/04/18 2:59 PM CDT I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night. How long does a cough last? Question 06/04/18 2:59 PM CDT I think the cough started four. . . No, it started five days ago. What is the duration of your cough? (Clarified to How would you describe your cough?.) Question 06/04/18 3:00 PM CDT My cough seems kind of gurgly and watery. What makes your cough worse? Question 06/04/18 3:00 PM CDT 2/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health My cough mostly stays the same no matter what I do. It seems to get worse at night though. Do you smoke? Question 06/04/18 3:01 PM CDT No way! I know smoking is really bad--even for grown-ups. Papi smokes cigars sometimes. I don't like how they smell. Do you know what triggers your cough? (No matching questions found.) Question 06/04/18 3:01 PM CDT What makes your cough worse? Question 06/04/18 3:01 PM CDT My cough mostly stays the same no matter what I do. It seems to get worse at night though. Are you exposed to anyone smoking? Question 06/04/18 3:02 PM CDT Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it's not all the time or anything. I don't like how it smells. Does your father smoke? Question 06/04/18 3:02 PM CDT Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it's not all the time or anything. I don't like how it smells. What makes your cough better? Question 06/04/18 3:03 PM CDT I had some cough medicine this morning. [AUDIO COMING SOON] Being exposed to secondhand smoke is almost just as bad as smoking, make sure you're around no one that is smoking Educate 06/04/18 3:03 PM CDT Oh, OK. 3/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health What type of cough medicine do you take? (Clarified to Can you describe the cough medicine to me.) Question 06/04/18 3:04 PM CDT Um, it was purple-ish. It tasted gross. Do you know how much cough medicine you take? Question 06/04/18 3:04 PM CDT I just had one spoonful of it. Who gives you the medication? Question 06/04/18 3:05 PM CDT My mom. Any other things you were doing for your cough? Question 06/04/18 3:05 PM CDT My nose is a runny and I just feel kind of tired. Oh . . . my throat hurts a little bit too. But just a little bit. Are you using any home remedies for your cough? Question 06/04/18 3:05 PM CDT I had some cough medicine this morning. [AUDIO COMING SOON] Home remedies for cough? Question 06/04/18 3:05 PM CDT I had some cough medicine this morning. [AUDIO COMING SOON] Are you taking anything else for your cough? (Clarified to are you taking other medications.) Question 06/04/18 3:06 PM CDT I'm not taking any medicines every day. My mom gave me some cough medicine this morning though. Do you typically take medication every day? (Clarified to do you take any medications daily.) Question 06/04/18 3:08 PM CDT 4/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health I don't take any medicines every day. Do you take a vitamin? Question 06/04/18 3:08 PM CDT Oh yeah, I take vitamins every day! The gummy dinosaur kind. I don't think I'm supposed to, but sometimes I sneak extra ones to be super healthy! You really should only take one as prescribed on the bottle of gummy dinosaurs Educate 06/04/18 3:10 PM CDT Oh, OK. How is your activity level? Question 06/04/18 3:10 PM CDT I have gym class every day. I do all my exercises there. Abuela always has to remind me to play outside for a little bit on the weekends. . . I guess I like to play inside more. How are your classes in school Question 06/04/18 3:11 PM CDT I like school, but I guess sometimes it makes me feel bored if the homework is too easy. Is it hard for you to focus? (No matching questions found.) Question 06/04/18 3:11 PM CDT Is it hard for you to focus in school? (No matching questions found.) Question 06/04/18 3:11 PM CDT how is your school focus? Question 06/04/18 3:11 PM CDT I like school, but I guess sometimes it makes me feel bored if the homework is too easy. With your cough are you still able to play? (No matching questions found.) Question 06/04/18 3:12 PM CDT 5/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Is your cough interfering with your play Question 06/04/18 3:12 PM CDT I don't usually wake up once I go to bed, but my cough has made it hard to fall asleep. Does your cough make it difficult to run? Question 06/04/18 3:12 PM CDT I don't usually wake up once I go to bed, but my cough has made it hard to fall asleep. How is your activity level? Question 06/04/18 3:13 PM CDT I have gym class every day. I do all my exercises there. Abuela always has to remind me to play outside for a little bit on the weekends. . . I guess I like to play inside more. It is always good to have physical exercise Educate 06/04/18 3:14 PM CDT Oh, OK. Do you have a runny nose? Question 06/04/18 3:14 PM CDT My nose is always a little bit runny... but ever since I started coughing it's been worse, I think. Sneezing? Question 06/04/18 3:14 PM CDT I don't usually have to sneeze. My nose gets runny a lot of times though, like I have a cold. How often do you have a runny nose? Question 06/04/18 3:14 PM CDT Yeah, um, my nose is runny right now... it always seems a little bit runny. What color is your nasal discharge? 6/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Question 06/04/18 3:15 PM CDT You mean like when I blow my nose? It's clear. Is the drainage from your nose thin? Question 06/04/18 3:15 PM CDT My nose is always a little bit runny... but ever since I started coughing it's been worse, I think. What is the consistency of your nasal drainage? Question 06/04/18 3:15 PM CDT It's kind of clear and, like, watery. Are you having any pain? Question 06/04/18 3:16 PM CDT Nothing really hurts. I've just had this cough for about five days. . . and I feel kind of tired. On a Pain Scale of 0 to 10 what would you rate your pain? Question 06/04/18 3:16 PM CDT Well, I have a little pain . . . in my right ear. Maybe almost a 3. Yeah. It's not too bad. I'm sorry you're in pain Empathize 06/04/18 3:17 PM CDT Thank you. Are you having pain in your ears? Question 06/04/18 3:17 PM CDT My right ear is starting to hurt a little bit . . . my left one is OK though. history of ear infections? (Clarified to have you ever had ear infections.) Question 06/04/18 3:18 PM CDT 7/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health The last time I had one was when I was little. Mom said I used to get them a lot. Maybe I was 2-years-old? Oh, my right ear kind of hurts now . . . Do you have any ear drainage? Question 06/04/18 3:18 PM CDT No, nothing comes out of my ears, but my right ear kind of hurts. I'm sorry to hear that Empathize 06/04/18 3:18 PM CDT Thank you. Do you have any hearing problems? Question 06/04/18 3:18 PM CDT A lady came to my school to give all the kids a hearing test. It was kind of cool! I was hoping I would have super hearing, but I think I was just normal . . . When did you have your hearing test? (Clarified to when was the last time you had your hearing tested.) Question 06/04/18 3:19 PM CDT A lady came to school this year to give us a hearing test. Maybe a month ago? I was hoping I would have super hearing, but it was just normal. . . Do you have a sore throat? Question 06/04/18 3:20 PM CDT It feels a little bit sore, yeah. Does it hurt to swallow? Question 06/04/18 3:20 PM CDT No, I can swallow OK. It hurts a little right now because my throat is kinda sore. I'm sorry your throat hurt. Empathize 06/04/18 3:21 PM CDT 8/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Thank you. Do you have a history of asthma? Question 06/04/18 3:21 PM CDT Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don't have to. Are your immunizations current? Question 06/04/18 3:21 PM CDT Like getting shots? It seems like I get shots whenever I go to the doctor. Mom says I need them for school, but I hate it. Have you ever had pneumonia? Question 06/04/18 3:21 PM CDT I think I had that last year, when I was seven. My mom was really worried. Do you have a history of frequent cough? Question 06/04/18 3:22 PM CDT I sometimes get coughs like this, but it's not all the time. I don't think it's a lot. I coughed a lot was when I had pneumonia one time. Do you have seasonal allergies? Question 06/04/18 3:23 PM CDT I don't think I have any allergies like that. Do you have any food allergies? Question 06/04/18 3:23 PM CDT I'm not allergic to any foods I don't think. Do you have any medication allergies? Question 06/04/18 3:23 PM CDT I don't think I'm allergic to medicine. 9/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Have you had any fever? Question 06/04/18 3:24 PM CDT My mom said I didn't have a fever this morning before Abuela took me here. Is your activity the same with your cough? (Clarified to Does activity make your cough worse?.) Question 06/04/18 3:25 PM CDT I don't think so. My cough stays the same. I just felt tired during recess, so I went inside to use the classroom computer. Did you get your flu vaccine? Question 06/04/18 3:26 PM CDT I don't think I have had a flu shot. . . at least not this year. Is important that you have a flu shot every year. Educate 06/04/18 3:26 PM CDT Oh, OK. Were you hospitalized for pneumonia Question 06/04/18 3:28 PM CDT Well, I got it last year when I was seven. I had to go to the clinic at night instead of my regular doctor. Mom was really worried, but it got better after some rest and medicine. Does your father have a history of asthma? (Clarified to does your father have health problems.) Question 06/04/18 3:28 PM CDT Papi has sometimes says his blood pressure is high. He always says he has to watch his cholesterol too. Oh, he smokes too. I know that's bad for him. . . Mom tells him not to because he had asthma when he was a little kid. Any family history of allergies? Question 06/04/18 3:29 PM CDT I don't think so, but I guess I'm not sure. 10/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Checked vitals Tested lung capacity with spirometer: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%) Exam Action 06/04/18 3:35 PM CDT Exam Action 06/04/18 3:40 PM CDT Inspected left orbital area and sclera Exam Action 06/04/18 3:44 PM CDT Inspected right orbital area and sclera Exam Action 06/04/18 3:44 PM CDT Inspected upper conjunctiva Exam Action 06/04/18 3:44 PM CDT Inspected lower conjunctiva Exam Action 06/04/18 3:44 PM CDT Performed otoscopic examination of left naris Exam Action 06/04/18 3:45 PM CDT Performed otoscopic examination of right naris Exam Action 06/04/18 3:45 PM CDT Performed otoscopic examination of left ear Exam Action 06/04/18 3:45 PM CDT Performed otoscopic examination of right ear Exam Action 06/04/18 3:46 PM CDT Performed otoscopic examination of left ear Exam Action 06/04/18 3:46 PM CDT Performed otoscopic examination of right ear Exam Action 06/04/18 3:46 PM CDT Performed otoscopic examination of left ear Exam Action 06/04/18 3:46 PM CDT 11/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Inspected mouth Exam Action 06/04/18 3:47 PM CDT Inspected front of neck Exam Action 06/04/18 3:48 PM CDT Inspected left side of neck Exam Action 06/04/18 3:48 PM CDT Inspected back of neck Exam Action 06/04/18 3:48 PM CDT Inspected right side of neck Exam Action 06/04/18 3:48 PM CDT Inspected front of neck Exam Action 06/04/18 3:48 PM CDT Inspected mouth Exam Action 06/04/18 3:48 PM CDT Inspected mouth Exam Action 06/04/18 3:48 PM CDT Inspected anterior chest wall Exam Action 06/04/18 3:49 PM CDT Inspected posterior chest wall Exam Action 06/04/18 3:49 PM CDT Inspected anterior chest wall Exam Action 06/04/18 3:49 PM CDT Palpated frontal sinuses: No tenderness reported Exam Action 06/04/18 3:49 PM CDT Palpated maxillary sinuses: No tenderness reported Exam Action 06/04/18 3:49 PM CDT 12/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side Exam Action 06/04/18 3:51 PM CDT Palpated supraclavicular lymph nodes: Not palpable Exam Action 06/04/18 3:51 PM CDT Palpated axillary lymph nodes: Not palpable Exam Action 06/04/18 3:51 PM CDT Palpated axillary lymph nodes: Not palpable Exam Action 06/04/18 3:51 PM CDT Palpated axillary lymph nodes: Not palpable Exam Action 06/04/18 3:51 PM CDT Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally Exam Action 06/04/18 3:53 PM CDT Ninety-nine. Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally Exam Action 06/04/18 3:53 PM CDT Ninety-nine. Auscultated breath sounds in anterior left upper lobe Exam Action 06/04/18 3:53 PM CDT Auscultated breath sounds in anterior right upper lobe Exam Action 06/04/18 3:53 PM CDT Auscultated breath sounds in anterior right middle lobe Exam Action 06/04/18 3:53 PM CDT Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 06/04/18 3:53 PM CDT Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 06/04/18 3:53 PM CDT 13/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Auscultated breath sounds in anterior right middle lobe Exam Action 06/04/18 3:53 PM CDT Auscultated breath sounds in anterior left lower lobe Exam Action 06/04/18 3:53 PM CDT Auscultated breath sounds in anterior right lower lobe Exam Action 06/04/18 3:53 PM CDT Auscultated breath sounds in posterior left upper lobe Exam Action 06/04/18 3:54 PM CDT Auscultated breath sounds in posterior right upper lobe Exam Action 06/04/18 3:54 PM CDT Auscultated breath sounds in posterior right mid-back (lower lobe) Exam Action 06/04/18 3:54 PM CDT Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action 06/04/18 3:54 PM CDT Auscultated breath sounds in posterior left lower lobe near spine Exam Action 06/04/18 3:54 PM CDT Auscultated breath sounds in posterior right lower lobe near spine Exam Action 06/04/18 3:54 PM CDT Auscultated breath sounds in posterior right lower lobe on side Exam Action 06/04/18 3:54 PM CDT Auscultated breath sounds in posterior right lower lobe Exam Action 06/04/18 3:54 PM CDT Auscultated breath sounds in posterior left lower lobe Exam Action 06/04/18 3:54 PM CDT Auscultated breath sounds in posterior left lower lobe on side Exam Action 06/04/18 3:54 PM CDT 14/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Auscultated voice sounds in anterior left upper lobe Exam Action 06/04/18 3:54 PM CDT Ninety-nine. Ninety-nine. Ninety-nine. Auscultated voice sounds in anterior right upper lobe Exam Action 06/04/18 3:54 PM CDT Ninety-nine. Auscultated voice sounds in anterior right middle lobe Exam Action 06/04/18 3:54 PM CDT Auscultated voice sounds in anterior left mid-chest (upper lobe) Exam Action 06/04/18 3:55 PM CDT Ninety-nine. Auscultated voice sounds in anterior left mid-chest (upper lobe) Exam Action 06/04/18 3:55 PM CDT Auscultated voice sounds in anterior right middle lobe Exam Action 06/04/18 3:55 PM CDT Auscultated voice sounds in anterior right lower lobe Exam Action 06/04/18 3:55 PM CDT Ninety-nine. Auscultated voice sounds in anterior left lower lobe Exam Action 06/04/18 3:55 PM CDT Ninety-nine. 15/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Ninety-nine. Ninety-nine. Auscultated voice sounds in posterior left upper lobe Exam Action 06/04/18 3:55 PM CDT Ninety-nine. Ninety-nine. Auscultated voice sounds in posterior right upper lobe Exam Action 06/04/18 3:55 PM CDT Ninety-nine. Auscultated voice sounds in posterior right mid-back (lower lobe) Exam Action 06/04/18 3:55 PM CDT Auscultated voice sounds in posterior left mid-back (lower lobe) Exam Action 06/04/18 3:55 PM CDT Ninety-nine. Auscultated voice sounds in posterior left lower lobe near spine Exam Action 06/04/18 3:55 PM CDT Ninety-nine. Auscultated voice sounds in posterior right lower lobe on side Exam Action 06/04/18 3:55 PM CDT Ninety-nine. Auscultated voice sounds in posterior right lower lobe Exam Action 06/04/18 3:55 PM CDT 16/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Auscultated voice sounds in posterior left lower lobe Exam Action 06/04/18 3:55 PM CDT Auscultated voice sounds in posterior left lower lobe on side Exam Action 06/04/18 3:55 PM CDT Auscultated voice sounds in posterior right lower lobe near spine Exam Action 06/04/18 3:55 PM CDT Auscultated aortic area with the bell Exam Action 06/04/18 3:55 PM CDT Auscultated aortic area with the diaphragm Exam Action 06/04/18 3:56 PM CDT Auscultated pulmonic area with the diaphragm Exam Action 06/04/18 3:56 PM CDT Auscultated pulmonic area with the bell Exam Action 06/04/18 3:56 PM CDT Auscultated Erb's point with the bell Exam Action 06/04/18 3:56 PM CDT Auscultated Erb's point with the diaphragm Exam Action 06/04/18 3:56 PM CDT Auscultated tricuspid area with the diaphragm Exam Action 06/04/18 3:56 PM CDT Auscultated tricuspid area with the bell Exam Action 06/04/18 3:56 PM CDT Auscultated mitral area with the bell Exam Action 06/04/18 3:56 PM CDT Auscultated mitral area with the diaphragm Exam Action 06/04/18 3:56 PM CDT 17/21 6/4/2018 Focused Exam: Cough | Completed | Shadow Health Percussed anterior right upper lobe Exam Action 06/04/18 3:57 PM CDT Percussed anterior left upper lobe Exam Action 06/04/18 3:57 PM CDT Percussed anterior left mid-chest (upper lobe) Exam Action 06/04/18 3:57 PM CDT Percussed anterior right middle lobe Exam Action 06/04/18 3:57 PM CDT Percussed anterior right lower lobe Exam Action 06/04/18 3:57 PM CDT Percussed anterior left lower lobe Exam Action 06/04/18 3:57 PM CDT Percussed posterior left upper lobe Exam Action 06/04/18 3:57 PM CDT Percussed posterior right upper lobe Exam Action 06/04/18 3:57 PM CDT Percussed posterior left mid-back (lower lobe) Exam Action 06/04/18 3:57 PM CDT Percussed posterior right mid-back (lower lobe) Exam Action 06/04/18 3:57 PM CDT Percussed posterior left lower lobe Exam Action 06/04/18 3:57 PM CDT Percussed posterior right lower lobe Exam Action 06/04/18 3:57 PM CDT Percussed posterior left right lobe on side Exam Action 06/04/18 3:57 PM CDT 18/21 6/4/2018 Focused Exam: Cough | Completed | Shadow ...
View Full Document

  • Fall '15
  • French Revolution, Right-wing politics, cough, Left-wing politics, Common cold, Political spectrum

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern

Stuck? We have tutors online 24/7 who can help you get unstuck.
A+ icon
Ask Expert Tutors You can ask You can ask You can ask (will expire )
Answers in as fast as 15 minutes