NURS 6512 Week 5 Focused Exam Cough Danny Rivera
NURS 6512 Week 5 Focused Exam Cough Danny Rivera
Experience Overview
Patient: Danny Rivera
Digital Clinical Experience Score
93.4%
This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.
Student Performance Index
35.27
out of 39
|
Proficiency Level:
Subjective Data Collection
out of
Objective Data Collection
out of
Education and Empathy
out of
Time
903 minutes total spent in assignment |
Interaction with patient
903 minutes
Transcript – NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera
Hi Danny my name is …., I am here to examine you today.
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Greet |
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Hi.
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How are you doing today ?
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Question |
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I don’t feel so good. I keep coughing and I feel a little bit tired.
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Oh, I’m sorry to hear that Danny
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Empathize |
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Thank you.
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How is the characteristics of your cough ?
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Question |
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My cough seems kind of gurgly and watery.
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Do you have a cough ?
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Question |
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I guess I’m kind of sick. . . I’ve been coughing a lot.
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How often do you have a cough ?
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Question |
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I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
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When it started ? (Clarified to When did the cough start?.)
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Question |
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I think the cough started four. . . No, it started five days ago. (Clarified to when the cough started.)
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How frequently have you been coughing ?
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Question |
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I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
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Is your cough wet cough ?
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Question |
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Yeah . . . my cough seems kind of gurgly and watery.
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Do you have a sputum ?
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Question |
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Sometimes I cough up this slimy, clear stuff.
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What aggravates your cough ?
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Question |
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My cough mostly stays the same no matter what I do. It seems to get worse at night though.
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Do you smoke ?
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Question |
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No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell.
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Lisa poppy smokes at home around you (No matching questions found.)
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Question |
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Lisa poppy smokes at home around you ? (No matching questions found.)
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Question |
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Lisa Papi smokes at home around you ? (No matching questions found.)
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Question |
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Is Papi smokes at home around you ?
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Question |
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Yeah, sometimes Papi smokes cigars inside. He forgets to take them outside and my mom has to remind him. [AUDIO COMING SOON]
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It’s called secondary smoke When someone at home smokes they need to go to outside. Please dont be around the people who smoking. It is called secondary smoke. If you see somebody smoking and have no intentions to leave or you coming to the place where somebody smoked please do not stay in the same area. You need to leave. It is called secondary smoking and may affect your lungs when you inhale the smoke.NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera
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Educate |
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Oh, OK.
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Are there anything makes your cough worse ?
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Question |
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My cough mostly stays the same no matter what I do. It seems to get worse at night though.
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What helps you cough ?
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Question |
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I had some cough medicine this morning. [AUDIO COMING SOON]
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Resting helps you ? (Clarified to Does rest relieve your cough?.)
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Question |
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My cough has just stayed the same. I’ve taken some naps, but it doesn’t seem to help. (Clarified to if rest relieves my cough.)
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Does drinking water helps your cough ?
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Question |
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Drinking water doesn’t do anything to my cough.
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Do you have any nasal problems ?
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Question |
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My nose doesn’t get stuffed up. Oh, sometimes it gets runny though.
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Do you sneeze ?
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Question |
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I don’t usually have to sneeze. My nose gets runny a lot of times though, like I have a cold.
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Do you have rhinorrhea ?
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Question |
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I don’t have a rhino. My mom won’t even let me get a lizard. [AUDIO COMING SOON] NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera
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Get runny nose often ?
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Question |
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My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
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Do you have a nasal discharge ?
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Question |
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My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
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Is there a discharge from your nose is clear ? (Clarified to Is the runny stuff from your nose clear?.)
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Question |
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You mean like when I blow my nose? It’s clear. (Clarified to if my nasal discharge is clear.)
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Is this stuff coming out from your nose is thin ? (Clarified to Is the runny stuff from your nose thick?.)
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Question |
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It’s kind of clear and, like, watery. (Clarified to if I have thick nasal discharge.)
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How about your ears ? (Clarified to How are your ears?.)
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Question |
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My right ear is starting to hurt a little bit . . . my left one is OK though. (Clarified to how my ears are.)
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Do you have any ear pain ?
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Question |
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My right ear is starting to hurt a little bit . . . my left one is OK though.
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How long have you had a ear pain ?
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Question |
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My right ear just started hurting yesterday. I think it’s because I’m sick.
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What is European from 1 to 10 ? (Clarified to How would you rate your ear pain on a 0-10 scale?.)
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Question |
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Oh, I think it just hurts a little bit . . . three? (Clarified to how I would rate my ear pain on a scale.)
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Do you have any discharge from your ears ?
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Question |
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No, nothing comes out of my ears, but my right ear kind of hurts.
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Do you have any problem in your throat ?
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Question |
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My throat is sore, but just a little bit.
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Do you have a pain when you swallow ?
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Question |
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No, I can swallow OK. It hurts a little right now because my throat is kinda sore.
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What type of medication do you take ?
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Question |
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I took some cough medicine this morning. [AUDIO COMING SOON]
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What does the name of cough medication ? (Clarified to Do you know what the cough medication’s name is?.)
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Question |
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I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON] (Clarified to if I know what the cough medicine is called.)
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You take vitamins ? (Clarified to Do you take a multivitamin every day?.)
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Question |
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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! (Clarified to if I take a vitamin every day.)NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera
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It’s not good to take the extra one because it is important medication or vitamins dosages and the excess amount may hurt you.
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Educate |
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Oh, OK.
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How you taking medication for your cough ? (Clarified to Have you taken medicine for your cough?.)
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Question |
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I had some cough medicine this morning. [AUDIO COMING SOON] (Clarified to if I have taken medicine for my cough.)
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What does the color of your cough medication ? (Clarified to Can you describe the cough medicine to me?.)
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Question |
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Um, it was purple-ish. It tasted gross. (Clarified to to describe the cough medicine.)
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What is the amount of this medication you’re taking?
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Question |
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I took some cough medicine this morning. [AUDIO COMING SOON]
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How much of cough medication you took ? (Clarified to How much did you take of the cough medication?.)
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Question |
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I just had one spoonful of it. (Clarified to how much cough medicine I took.)
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Who give use a cough medicine ?
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Question |
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My mom.
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It’s a cough medication makes you feel better ?
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Question |
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It helped a bit when my mom gave it to me, but my cough came back anyway.
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Do you have any allergies ?
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Question |
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I don’t really have any allergies. Tony has some though. He’s allergic to bees.
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Do you have any food allergies ?
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Question |
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I’m not allergic to any foods I don’t think.
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Are you allergic to any animals ?
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Question |
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I’m not allergic to any animals, which is good because I like them.
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Do you have any let latex allergy ?
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Question |
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I don’t really have any allergies. Tony has some though. He’s allergic to bees.
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Who is Tony ?
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Question |
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Tony’s my best friend.
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Do you have any past medical history ?
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Question |
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Oh, well, I have been sick before and I’m sick now . . . I had pneumonia once. Last year. My mom was really scared. She says I used to get earaches a lot too.
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Do you have any asthma ?
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Question |
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Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don’t have to.
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How was your immunizations ? (Clarified to What immunizations have you had?.)
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Question |
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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. (Clarified to what vaccines I have had.)
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Have you ever been in the hospital ?
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Question |
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I have never been to the hospital. My mom likes to watch doctor shows on TV, so I kind of know what it’s like.
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Who smokes at home ?
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Question |
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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.
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Where does your father smoke ?
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Question |
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Sometimes Papi forgets to go outside with his cigars. He’s usually in the kitchen or the living room when that happens.
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Do you have any unusual frequent colds ?
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Question |
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I get colds a lot. My nose is always runny.
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Do you have a fever ?
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Question |
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My mom said I didn’t have a fever this morning before Abuela took me here.
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Do you have a chills ?
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Question |
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No, I haven’t felt that.
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Do you have a weakness ?
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Question |
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I haven’t felt weak. . . I’m just kind of tired because my cough keeps me up at night.
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Do you have any night sweats ?
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Question |
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I don’t sweat at night unless it gets really hot or something.
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Have you lost weight ?
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Question |
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I guess I gained some weight actually. Some kids at recess called me chubby . . . My mom says I’m just growing though.
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How is your appetite ?
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Question |
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I think my appetite is normal.
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Do you have any ear crackling or popping ?
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Question |
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No, I haven’t noticed any popping in my ears, but my right ear kind of hurts.
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Do you have any popping sounds ?
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Question |
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No, I haven’t noticed any popping in my ears, but my right ear kind of hurts.
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Have you ever had any ear infections ?
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Question |
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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 . . .
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Have you ever had any surgery on your ears?
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Question |
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Mom says I used to get ear infections a lot when I was little, but I’m pretty sure I never had surgery for it.NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera
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Do you get headaches ?
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Question |
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I don’t usually get headaches.
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Do you have nose bleeds ?
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Question |
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Just one time. Tony and I were kicking a ball at recess and I got hit in the nose.
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Do you get dizzy ?
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Question |
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I only get dizzy if I’m spinning around a lot at recess.
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Your eyes getting watery ?
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Question |
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No, my eyes don’t tear up. Well, I guess if I get sad or Papi is chopping onions for dinner they might.
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Is your eyes getting red?
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Question |
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I don’t think my eyes are ever red.
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Do you have eye pain?
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Question |
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No, my eyes don’t hurt, but they kind of feel like they do when I’m tired.
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Do you have any sinus pain?
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Question |
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It doesn’t hurt there.
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Do you have hearing problems ?
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Question |
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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 . . .
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How was your breathing ?
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Question |
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My breathing seems good. My nose is kind of runny right now, but I can still breathe OK.
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Do you have any chest tightness?
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Question |
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My chest feels okay.
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Do you have any chest pain ?
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Question |
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No, I don’t have pain in my chest. I would hate that!
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Have you ever had any medications at in you inhaled ? (Clarified to Have you used an inhaler?.)
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Question |
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No, I don’t use one of those. My friend Tony does though! (Clarified to if I have used an inhaler.)
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Is anybody sick in your house ?
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Question |
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Nobody at home is sick I don’t think.
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Do you have any family history of asthma ?
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Question |
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Mom says Papi had asthma when he was a little kid.
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Anybody in your family has allergies ?
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Question |
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I don’t think so, but I guess I’m not sure.
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Do you have any pets at home ?
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Question |
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No, but I keep asking my mom if I can get a lizard.
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Where do you go when you have a free time ? (No matching questions found.)
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Question |
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What do you do when you have a free time ?
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Question |
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Usually I play video games or read or try to write stories. If Tony is here, we do that stuff together.
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How often you around smoking people ? (Clarified to How often are you around people who smoke?.)
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Question |
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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. (Clarified to how often I am around secondhand smoke.)
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Do you wash your hands ?
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Question |
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I wash my hands before I eat or after I go to the bathroom.
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How often do you wash your hands?
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Question |
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I wash my hands before I eat or after I go to the bathroom.
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Do you touch your nose often ?
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Question |
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My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
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You need to wash your hands more often.When you come from somewhere.
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Educate |
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Oh, OK.
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You need to wash your hands after you touch your nose. You may transfer a lot of infections or bacteria from your nose to door handles for example. If you dont wash your hands more often you can contaminate yourself or others with bacteria and possible viruses fro unwashed hands.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera
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Educate |
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Oh, OK.
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Checked vitals
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Exam Action |
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Tested lung capacity with spirometer: FEV1: 1.78L, FVC 1.549L (FEV1/FVC: 87%)
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Exam Action |
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Inspected mouth
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Exam Action |
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Inspected front of neck
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Exam Action |
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Inspected anterior chest wall
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Exam Action |
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Palpated maxillary sinuses: No tenderness reported
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Exam Action |
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Palpated frontal sinuses: No tenderness reported
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Exam Action |
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Palpated maxillary sinuses: No tenderness reported
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Exam Action |
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Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side
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Exam Action |
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Palpated axillary lymph nodes: Not palpable
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Exam Action |
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Palpated axillary lymph nodes: Not palpable
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Exam Action |
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Palpated supraclavicular lymph nodes: Not palpable
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Exam Action |
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Palpated axillary lymph nodes: Not palpable
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Exam Action |
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Palpated supraclavicular lymph nodes: Not palpable
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Exam Action |
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Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally
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Exam Action |
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Ninety-nine.
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Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally
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Exam Action |
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Ninety-nine.
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Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally
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Exam Action |
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Ninety-nine.
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Palpated fremitus in posterior upper chest wall: Expected fremitus, equal bilaterally
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Exam Action |
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Ninety-nine.
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Palpated fremitus in posterior middle chest wall: Expected fremitus, equal bilaterally
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Exam Action |
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Ninety-nine.
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Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally
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Exam Action |
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Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally
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Exam Action |
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Ninety-nine.
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Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally
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Exam Action |
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Ninety-nine.
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Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally
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Exam Action |
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Ninety-nine.
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Auscultated breath sounds in anterior right upper lobe
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Exam Action |
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Auscultated breath sounds in anterior left upper lobe
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Exam Action |
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Auscultated breath sounds in anterior left mid-chest (upper lobe)
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Exam Action |
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Auscultated breath sounds in anterior right middle lobe
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Exam Action |
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Auscultated breath sounds in anterior left mid-chest (upper lobe)
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Exam Action |
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Auscultated breath sounds in anterior right middle lobe
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Exam Action |
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Auscultated breath sounds in anterior right lower lobe
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Exam Action |
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Auscultated breath sounds in anterior left lower lobe
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Exam Action |
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Auscultated breath sounds in posterior right upper lobe
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Exam Action |
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Auscultated breath sounds in posterior left upper lobe
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Exam Action |
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Auscultated breath sounds in posterior left mid-back (lower lobe)
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Exam Action |
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Auscultated breath sounds in posterior right mid-back (lower lobe)
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Exam Action |
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Auscultated breath sounds in posterior left lower lobe near spine
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Exam Action |
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Auscultated breath sounds in posterior right lower lobe near spine
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Exam Action |
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Auscultated breath sounds in posterior right lower lobe
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Exam Action |
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Auscultated breath sounds in posterior left lower lobe
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Exam Action |
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Auscultated breath sounds in posterior left lower lobe on side
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Exam Action |
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Auscultated breath sounds in posterior right lower lobe on side
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Exam Action |
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Auscultated breath sounds in anterior left upper lobe
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Exam Action |
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Auscultated breath sounds in anterior right upper lobe
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Exam Action |
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Auscultated breath sounds in anterior right middle lobe
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Exam Action |
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Auscultated breath sounds in anterior left mid-chest (upper lobe)
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Exam Action |
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Auscultated breath sounds in anterior right middle lobe
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Exam Action |
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Auscultated breath sounds in anterior right lower lobe
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Exam Action |
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Percussed anterior right upper lobe
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Exam Action |
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Percussed anterior left upper lobe
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Exam Action |
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Percussed anterior right middle lobe
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Exam Action |
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Percussed anterior left mid-chest (upper lobe)
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Exam Action |
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Percussed anterior left lower lobe
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Exam Action |
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Percussed anterior right lower lobe
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Exam Action |
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Percussed posterior right upper lobe
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Exam Action |
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Percussed posterior left upper lobe
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Exam Action |
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Percussed posterior left mid-back (lower lobe)
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Exam Action |
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Percussed posterior right mid-back (lower lobe)
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Exam Action |
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Percussed posterior right lower lobe
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Exam Action |
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Percussed posterior right lower lobe near spine
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Exam Action |
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Percussed posterior left right lobe on side
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Exam Action |
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Percussed posterior left lower lobe near spine
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Exam Action |
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Percussed posterior left lower lobe
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Exam Action |
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Percussed posterior left lower lobe on side
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Exam Action |
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Percussed posterior left lower lobe on side
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Exam Action |
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Percussed posterior left lower lobe on side
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Exam Action |
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Checked vitals
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Exam Action |
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Do you have sick friends ?
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Question |
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None of my friends are sick that I know of.
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Do you have anybody passing it around you ? (No matching questions found.)
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Question |
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Do you have your friend Tony coughing around you ? (Clarified to Is tony sick?.)
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Question |
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None of my friends are sick that I know of. (Clarified to if Tony is sick.)
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Are you touching your nose ? (No matching questions found.)
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Question |
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How often do you touch your nose ? (Clarified to How often do you blow your nose?.)
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Question |
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Probably a million-billion times a day. [AUDIO COMING SOON] (Clarified to how often I blow my nose.)
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Danny, signs you have been sick for last few days it’s very important that you practice strict hand hygiene and respiratory hygiene because you can develop upper respiratory infection. It is extremely important to prevent it. NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera
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Educate |
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Oh, OK.
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Is anybody in your class sick ?
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Question |
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Nobody I know is sick, I don’t think.
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How is the Tony feels ?
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Question |
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None of my friends are sick that I know of.
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What type of diet do you have ?
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Question |
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Mom says I’m picky. I can clean my plate… if I like the food. Yeah. I eat breakfast and I eat all my dinner.
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What do you like to eat for breakfast ?
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Question |
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I have cereal with milk and fruit most mornings. Sometimes I have a waffle or eggs and bacon.
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Do you do exercises ?
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Question |
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I have gym class every day. I do all my exercises there. And there’s a park right next to my house where I play after school, or sometimes on the weekends, if it’s nice outside. [AUDIO COMING SOON]
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Can you minimize the amount of waffle and bacon which is not good for your health. It is low in nutritions and high in fats and carbohydrates.
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Educate |
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Oh, OK.
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Also I would like to recommend you to increase your fluid intake. It will help your body to be clean and to get rid of bacterias and infections.
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Educate |
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Oh, OK.
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Inspected mouth
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Exam Action |
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Can I take a look at your mouth again ?
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Question |
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Sure.
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Performed otoscopic examination of right ear
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Exam Action |
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Can I examine you more Danny ?
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Question |
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Sure.
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Performed otoscopic examination of left ear
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Exam Action |
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Performed otoscopic examination of right ear
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Exam Action |
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Performed otoscopic examination of left ear
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Exam Action |
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Inspected mouth
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Exam Action |
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Danny how often you washing your hands ?
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Question |
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I wash my hands before I eat or after I go to the bathroom.
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You need to wash your hands more often or to use hand sanitizer.
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Educate |
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Oh, OK.
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Do you play with a sick peer ?
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Question |
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I have a lot of girls that are friends, but no girlfriends really. Not yet! There are some girls I think are pretty though.
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When your cough started ?
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Question |
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I think the cough started four. . . No, it started five days ago.
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Where do you have your pain ?
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Question |
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My right ear kind of hurts . . . but it’s just my cough that has been keeping me up at night. Oh, well, my throat is a little bit sore.
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Do you have any discharge from your right ear ?
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Question |
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No, nothing comes out of my ears, but my right ear kind of hurts.
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Do you have sore throat ?
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Question |
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It feels a little bit sore, yeah.
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How would you describe your pain ?
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Question |
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Um. . . I don’t know. It just hurts. But it’s not so bad.
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In a scale from 1 to 10 how would you describe your pain ? (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)
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Question |
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Well, I have a little pain . . . in my right ear. Maybe almost a 3. Yeah. It’s not too bad. (Clarified to how I would rate my pain on a scale.)
|
||
Do you take something for pain ? (Clarified to Are you taking anything for pain?.)
|
Question |
|
I don’t take medicine for pain. I only take the medicine my mom or Abuela give me. (Clarified to if I am taking pain medication.)
|
||
Who is Abuela ?
|
Question |
|
Abuela is my grandma . . . she’s my mom’s mom!
|
||
Did you say your pain like watery and gurgle ? (No matching questions found.)NURS6512 Week 5 – Focused Exam: Cough Danny Rivera
|
Question |
|
Did you say your pain like watery and gurgle ? (No matching questions found.)
|
Question |
|
Did you say that your pain pills like watery ? (No matching questions found.)
|
Question |
|
How was your pain in your throat feels like ?
|
Question |
|
Um, it just feels kind of sore. I can feel it a little bit when I swallow.
|
||
Oh, I am sorry to hear that Danny.
|
Empathize |
|
Thank you.
|
||
Danny how much water do you take ?
|
Question |
|
I drink water a lot. . . whenever I’m not drinking it enough, Abuela always makes me drink more.
|
||
How many cups of water do you drink per day ?
|
Question |
|
I usually have 7 or 8 glasses of water a day.
|
||
Is Tony used uses an inhaler ? (Clarified to Is Tony your brother?.)
|
Question |
|
Tony’s my best friend. (Clarified to if Tony is my brother.)
|
||
Do you know is Tony uses inhaler
|
Question |
|
None of my friends are sick that I know of.
|
||
Danny you need to stay away from sick people ok ?
|
Educate |
|
Oh, OK.
|
||
Danny, if you see that people around you coughing and sneezing you dont need to keep close communications with them. Also I will let your parents to provide you with hand sanitizer, you need to use it after using bathroom, if you touched some doors or any other interactions and touching other things.
|
Educate |
|
Oh, OK.
|
||
Also drink plenty of fluids are very important for your body. It will help to loosen the mucus in your nose and help congestion when you have symptoms of infections like you do now.
|
Educate |
|
Oh, OK.
|
||
When you cough, you need to cough into the tissue. If you dont have a tissue, use the sleeve to cover the mouth.
|
Educate |
|
Oh, OK.
|
||
I am going to tell your father not to smoke in the house. You remind him too if he forgets or go to other room. I will follow up about it.
|
Educate |
|
Oh, OK.
|
||
Danny I would like to communicate with your parents about todays recommendations and schedule follow up appointment. Are you ok with that ? (No matching questions found.)
|
Question |
|
Danny, I would like to communicate with your parents about todays recommendations and schedule follow up appointment.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera
|
Educate |
|
Oh, OK.
|
||
Also, please do not touch your face, nose, mouth, eyes with your hands. You can transmit more infection to yourself and others which we need to prevent. (No matching questions found.)
|
Question |
|
Also, please do not touch your face, nose, mouth, eyes with your hands. You can transmit more infection to yourself and others which we need to prevent.
|
Educate |
|
Oh, OK.
|
||
Do you have a pain now ? (Clarified to Do you have pain right now?.)
|
Question |
|
The only thing that really hurts is my right ear, but it just hurts a little bit. It just started . . . I’m not sure what will make it feel better. (Clarified to if I am in pain right now.)
|
||
I’m sorry to hear that
|
Empathize |
|
Thank you.
|
||
How often do you said you are coughing ?
|
Question |
|
I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
|
||
I’m sorry it must be really uncomfortable.
|
Empathize |
|
Thank you.
|
||
What type of medication are you taking for your cough ?
|
Question |
|
I took some cough medicine this morning. [AUDIO COMING SOON]
|
||
What type of medication is this ? (Clarified to What medications do you take?.)
|
Question |
|
I took some cough medicine this morning. [AUDIO COMING SOON] (Clarified to what medications I am taking.)
|
||
Do you know what is the name of this medication ? (Clarified to What is the name of the cough medicine you took?.)
|
Question |
|
I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON] (Clarified to what the name of the cough medicine is.)
|
||
do you know the name of the medication for the cough ?
|
Question |
|
I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON]
|
||
ok, I can ask your mom about it. (No matching questions found.)
|
Question |
|
How long does medication was relieving your symptoms ? (No matching questions found.)
|
Question |
|
How long does cough medication was relieving your symptoms ?
|
Question |
|
My mom gave me some medicine and it helped my cough a little bit, but it started again.
|
||
How long you tipped you feel better after taking this medication ? (Clarified to Did the medicine make your cough better?.)
|
Question |
|
It helped a bit when my mom gave it to me, but my cough came back anyway. (Clarified to if the medicine helped my cough.)
|
Subjective Data Collection: 21 of 21 (100.0%) – NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
-
Found:
Indicates an item that you found.
-
Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports cough
(Found)
Example Question:
History of Present Illness
Finding:
Asked about onset of cough
Finding:
Reports cough started 5 days ago
(Found)
Example Question:
Finding:
Asked about frequency and duration of cough
Finding:
Reports coughing every few minutes
(Found)
Example Question:
Finding:
Asked about character of cough
Finding:
Reports cough is wet
(Found)
Example Question:
Finding:
Reports clear sputum
(Found)
Example Question:
Finding:
Asked about aggravating factors for cough
Finding:
Reports cough is worse at night
(Found)
Example Question:
Finding:
Reports exposure to secondhand smoke
(Found)
Example Question:
Finding:
Denies knowing what makes the cough worse
(Found)
Example Question:
Finding:
Asked about relieving factors for cough
Finding:
Denies resting relieves cough
(Found)
Example Question:
Finding:
Denies drinking water relieves cough
(Found)
Example Question:
Finding:
Asked about nasal symptoms
Finding:
Reports current runny nose
(Found)
Example Question:
Finding:
Denies sneezing
(Found)
Example Question:
Finding:
Reports frequent runny nose
(Found)
Example Question:
Finding:
Followed up on nasal discharge
Finding:
Reports nasal discharge is clear
(Found)
Example Question:
Finding:
Reports nasal discharge is thin
(Found)
Example Question:
Finding:
Asked about ear symptoms
Finding:
Reports pain in right ear
(Found)
Example Question:
Finding:
Followed up on ear pain
Finding:
Reports ear pain started yesterday
(Found)
Example Question:
Finding:
Reports ear pain is a 3 out of 10
(Found)
Example Question:
Finding:
Denies ear discharge
(Found)
Example Question:
Finding:
Asked about throat symptoms
Finding:
Reports sore throat
(Found)
Example Question:
Finding:
Reports “a little” pain with swallowing
(Found)
Example Question:
Finding:
Asked about allergies
Finding:
Denies seasonal allergies
(Available)
Example Question:
Finding:
Denies food allergies
(Found)
Example Question:
Finding:
Denies medication allergies
(Available)
Example Question:
Finding:
Denies allergies to animals
(Found)
Example Question:
Finding:
Denies latex allergy
(Available)
Example Question:
Finding:
Asked about contact with illnesses
Finding:
Denies being around anyone ill at home
(Found)
Example Question:
Home Medications
Finding:
Asked about home medications
Finding:
Confirmed home medications
(Found)
Example Question:
Finding:
Reports taking a daily vitamin
(Found)
Example Question:
Finding:
Reports taking cough medicine
(Found)
Example Question:
Finding:
Followed up on cough medicine
Finding:
Reports cough medicine was purple
(Found)
Example Question:
Finding:
Reports taking one spoonful of cough medicine
(Found)
Example Question:
Finding:
Reports mother gave him the medicine
(Found)
Example Question:
Finding:
Reports cough medicine provided temporary relief
(Found)
Example Question:
Past Medical History
Finding:
Asked about relevant medical history
Finding:
Denies asthma diagnosis
(Found)
Example Question:
Finding:
Reports immunizations as current
(Found)
Example Question:
Finding:
Reports past pneumonia and frequent coughs
(Found)
Example Question:
Finding:
Denies past hospitalizations
(Found)
Example Question:
Social Determinants of Health
Finding:
Asked about exposure to secondhand smoke
Finding:
Reports father smokes cigars
(Found)
Example Question:
Finding:
Reports father sometimes forgets to take cigars outside
(Found)
Example Question:
Social History
Finding:
Asked about living conditions
Finding:
Reports living in a house with parents and grandparents
(Available)
Example Question:
Finding:
Reports feeling safe at home
(Available)
Example Question:
Finding:
Reports park with playground near home
(Found)
Example Question:
Review of Systems
Finding
Asked about constitutional health
Finding:
Denies fever
(Found)
Example Question:
Finding:
Denies chills
(Found)
Example Question:
Finding:
Reports feeling “kind of tired”
(Found)
Example Question:
Finding:
Denies night sweats
(Found)
Example Question:
Finding:
Denies weight loss
(Found)
Example Question:
Finding:
Denies appetite loss
(Found)
Example Question:
Finding:
Asked about review of systems for HEENT
Finding:
Denies ear popping or crackling
(Found)
Example Question:
Finding:
Reports history of frequent ear infections
(Found)
Example Question:
Finding:
Denies ear surgery or ear tubes
(Found)
Example Question:
Finding:
Denies headaches
(Found)
Example Question:
Finding:
Denies nosebleeds
(Found)
Example Question:
Finding:
Denies vision problems
(Available)
Example Question:
Finding:
Denies dizziness
(Found)
Example Question:
Finding:
Denies watery eyes
(Found)
Example Question:
Finding:
Denies eye redness
(Found)
Example Question:
Finding:
Denies eye pain
(Found)
Example Question:
Finding:
Denies sinus pain
(Found)
Example Question:
Finding:
Denies hearing problems
(Found)
Example Question:
Finding:
Asked about review of systems for respiratory
Finding:
Denies difficulty breathing
(Found)
Example Question:
Finding:
Denies chest tightness
(Found)
Example Question:
Fining:
Denies chest pain
(Found)
Example Question:
Finding:
Denies history of inhaler use or breathing treatments
- Correct
- Partially correct
- Incorrect
- Missed
- No visible abnormal findings
- Ptosis
- Eyelid edema
- Lesion
- Allergic shiners
- White
- Jaundice
- Injection
- Icterus
- Moist and pink
- Pale
- Dry appearance
- Erythema
- Edema
- No discharge
- Clear, watery discharge
- Purulent discharge
- Pink
- Erythemic
- Bluish
- No discharge
- Clear discharge
- Bloody discharge
- Purulent discharge
- Patent
- Decreased patency
- Not patent
- No additional visible abnormal findings
- Foreign body present
- Polyp
- Septum perforated
- Septum deviated
- Lesion
- Pink
- Erythemic
- Pallor
- Pearly gray
- Erythemic
- Opaque
- Yellow
- Not visible because of cerumen
- No visible abnormal findings
- Fluid observed
- Visible scars
- Bulging
- Perforation
- Retraction
- 5:00
- Cone of light distorted
- No discharge
- Cerumen
- Clear discharge
- Bloody discharge
- Purulent discharge
- Pink
- Erythemic
- Pallor
- Pearly gray
- Erythemic
- Opaque
- Yellow
- Not visible because of cerumen
- No visible abnormal findings
- Fluid observed
- Visible scars
- Bulging
- Perforation
- Retraction
- 7:00
- Cone of light distorted
- No discharge
- Cerumen
- Clear discharge
- Bloody discharge
- Purulent discharge
- Moist and pink
- Dry appearance
- Erythema
- No visible abnormal find ings
- Edema
- Erythema
- Pink
- Erythemic
- No abnormal findings
- Cobblestoning
- Exudate
- No discharge
- Clear discharge
- Purulent discharge
- Symmetric
- Asymmetric
- No visible abnormal findings
- Swelling
- Visible pulsation
- Visible mass
- Discoloration
- Symmetric
- Asymmetric
- No visible abnormal findings
- Rash or lesion
- AP diameter abnormal Intercostal retraction while breathing
- Excessive use of accessory muscles while breathing
- Pectus excavatum
- Skin growths (freckles or moles)
- Evidence of skin trauma (scar, laceration, or bruising)
- None reported
- Tenderness reported
- None reported
- Tenderness reported
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
- No palpable nodes
- Palpable nodes on right side
- Palpable nodes on left side
- Equal bilaterally
- Unequal bilaterally
- Expected fremitus
- Decreased fremitus
- Present in all areas
- Diminished in some areas
- Absent in some areas
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
- All areas clear
- Adventitious sounds in anterior right upper lobe
- Adventitious sounds in anterior right middle lobe
- Adventitious sounds in anterior right lower lobe
- Adventitious sounds in anterior left upper lobe
- Adventitious sounds in anterior left lower lobe
- Adventitious sounds in posterior right upper lobe
- Adventitious sounds in posterior right lower lobe
- Adventitious sounds in posterior left upper lobe
- Adventitious sounds in posterior left lower lobe
- Positive
- Negative
- S1 and S2 audible
- S1, S2, and S3 audible
- S1, S2, and S4 audible
- S1, S2, S3, and S4 audible
- No extra sounds
- Gallops
- Murmur
- Friction rub
- Valve clicks
- All areas resonant
- Some areas dull, some resonant
- Some areas hyperresonant, some resonant
- No areas of dullness
- Dullness, anterior right upper lobe
- Dullness, anterior right middle lobe
- Dullness, anterior right lower lobe
- Dullness, anterior left upper lobe
- Dullness, anterior left lower lobe
- Dullness, posterior right upper lobe
- Dullness, posterior right lower lobe
- Dullness, posterior left upper lobe
- Dullness, posterior left lower lobe
Education & Empathy : 3 of 5 (60.0%)
During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.
- Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
- Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
- Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
Description: Danny describes the symptoms that have been bothering him. |
||
How are you doing today ? |
Question |
|
I don’t feel so good. I keep coughing and I feel a little bit tired. |
||
Oh, I’m sorry to hear that Danny |
Empathize |
|
Thank you. |
||
How was your pain in your throat feels like ? |
Question |
|
Um, it just feels kind of sore. I can feel it a little bit when I swallow. |
||
Oh, I am sorry to hear that Danny. |
Empathize |
|
Thank you. |
||
Do you have a pain now ? (Clarified to: Do you have pain right now?) |
Question |
|
The only thing that really hurts is my right ear, but it just hurts a little bit. It just started . . . I’m not sure what will make it feel better. (Clarified to: if I am in pain right now) |
||
I’m sorry to hear that |
Empathize |
|
Thank you. |
||
How often do you said you are coughing ? |
Question |
|
I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night. |
||
I’m sorry it must be really uncomfortable. |
Empathize |
|
Thank you. |
||
Model Statement: “I’m sorry your ear and your throat hurt. I’ll take a look and we’ll see if we can help you feel better.” |
Description: Danny describes the medication he was given for his cough. |
||
What helps you cough ? |
Question |
|
I had some cough medicine this morning. [AUDIO COMING SOON] |
||
Resting helps you ? (Clarified to: Does rest relieve your cough?) |
Question |
|
My cough has just stayed the same. I’ve taken some naps, but it doesn’t seem to help. (Clarified to: if rest relieves my cough) |
||
Does drinking water helps your cough ? |
Question |
|
Drinking water doesn’t do anything to my cough. |
||
Model Statement: “Thanks for telling me what you know about the medications you take. I can ask your mom or your abuela for more information.” |
Description: Danny describes taking vitamins. |
||
You take vitamins ? (Clarified to: Do you take a multivitamin every day?) |
Question |
|
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! (Clarified to: if I take a vitamin every day) |
||
It’s not good to take the extra one because it is important medication or vitamins dosages and the excess amount may hurt you. |
Educate |
|
Oh, OK. |
||
Model Statement: “You’re right; taking vitamins can be good for you. However, sometimes taking too many vitamins can be bad for you. It’d be better if you don’t sneak extra vitamins — just take the amount that your mom gives you.” |
Description: Danny describes exposure to secondhand smoke at home. |
||
Do you smoke ? |
Question |
|
No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell. |
||
Is Papi smokes at home around you ? |
Question |
|
Yeah, sometimes Papi smokes cigars inside. He forgets to take them outside and my mom has to remind him. [AUDIO COMING SOON] |
||
It’s called secondary smoke When someone at home smokes they need to go to outside. Please dont be around the people who smoking. It is called secondary smoke. If you see somebody smoking and have no intentions to leave or you coming to the place where somebody smoked please do not stay in the same area. You need to leave. It is called secondary smoking and may affect your lungs when you inhale the smoke. |
Educate |
|
Oh, OK. |
||
Model Statement: “That’s too bad your Papi smokes cigars at home. It sounds like it bothers you. Breathing in smoke isn’t very healthy, so it’s good to stay out rooms where you can smell cigar smoke.” |
Description: Danny describes what he knows about his family health history. |
||
Is anybody sick in your house ? |
Question |
|
Nobody at home is sick I don’t think. |
||
Do you have any family history of asthma ? |
Question |
|
Mom says Papi had asthma when he was a little kid. |
||
Anybody in your family has allergies ? |
Question |
|
I don’t think so, but I guess I’m not sure. |
||
Do you have any pets at home ? |
Question |
|
No, but I keep asking my mom if I can get a lizard. |
||
What do you do when you have a free time ? |
Question |
|
Usually I play video games or read or try to write stories. If Tony is here, we do that stuff together. |
||
Model Statement: “Thanks for telling me what you know about your family history. You did a good job remembering.” |
Comments
Documentation / Electronic Health Record
Document: Vitals
Vitals | |
---|---|
Blood Pressure | 120/76 |
O2 Sat | 96 |
Pulse | 100 |
Resp. Rate | 28 |
Temperature | 37.2 |