NURS 6512 Assessing The Head, Eyes, Ears, Nose, And Throat Soap Note

NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat Soap Note

NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat Soap Note

Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Richard is a 50-year-old, white, male that presents to the clinic complaining of nasal congestion, rhinorrhea, and postnasal drainage. Over the past five days his nose, eyes, throat, and ears have been itchy. He has been taking Mucinex OTC the past two nights to help him breathe while he sleeps. The purpose of this paper is to create a focused SOAP note, provide possible conditions and diagnoses for the patient above and rationale.

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Episodic/Focused SOAP Note Template

Patient Information:

Patient Initials: R.B. Age: 50 Gender: Male Race: White

Subjective Data:

CC: Nasal congestion, sneezing, runny nose, itchy nose, eyes, and throat over the past 5 days.

HPI: 50-year-old white male presents to clinic with a runny nose, sneezing, and itchy nose, eyes and throat. Patient states he has been experiencing symptoms over the past 5 days. Patient reports feeling like the back of his throat is itching and pressure under his eyes and above his cheeks on both sides. He states it’s been difficult for him to breathe at night, and has been taking Mucinex OTC x2 days to help him sleep with little to no relief. He rates his pain 4/10 to his forehead and sides of nose which feels like dull pressure.

Current Medications:

Mucinex 600mg PO q12H PRN
Acetaminophen 650mg PO Q4H PRN pain
Lisinopril 10mg PO daily

Allergies:

Cats: itching and sneezing
Pollen: itching watering eyes, sneezing

Past Medical History (PMH):

HTN
Hyperlipidemia
Seasonal allergies

Past Surgical History (PSH):

Appendectomy 3/29/2002
Bilateral Cataract Removal with IOL implant 6/5/2017

Personal/Social History:

Alcohol Use: Denies

Caffeine Use: Current

Caffeine Type: Coffee

Caffeine Frequency: Daily

Tobacco/Nicotine Usage: Former, quit smoking in 2002

Recreational Drug Use: Denies

Significant Family History:

Father: HTN, Alcoholism

Mother: Healthy, no PMH

Paternal Grandfather: not living, MI, CAD, HTN, hyperlipidemia

Paternal Grandmother: Dementia, CVA, TIA

Maternal Grandmother: HTN

Maternal Grandfather: unknown

Sister: healthy, no PMH

Immunization History: Immunizations UTD, Tdap 2018, Influenza Vaccine 11/2019

Lifestyle: Patient lives at home with wife; employed at Altec as a machinist; lives just outside of town in a low crime area; financially stable with medical insurance. Walks 3 miles daily and follows a low fat, low carb diet. Patient has a good support system of wife, kids, and grandchildren. Sees his PCP yearly for routine care and PRN.

Review of Systems (ROS):

GENERAL: No weight loss, fever, chills, light headedness, weakness or fatigue. Complains of dull pressure to his forehead over the past 5 days.

HEENT: Denies any vision loss or double vision. States he has had cataracts removed bilaterally and sees well following surgery. Experiencing itchy watery eyes, nose, and throat. Nasal drainage is clear.

SKIN: No rashes or itching.

CARDIOVASCULAR: Denies any chest pain or heart palpitations.

RESPIRATORY: Complains of trouble breathing at night when laying down over the past 4-5 days due to “stopped up nose.”

GASTROINTESTINAL: Denies any changes in appetite or weight. No constipation or diarrhea.

GENITOURINARY: Denies any burning or trouble urinating. Denies incontinence or penile discharge.

NEUROLOGICAL: Complains of dull headache over the last 4-5 days, between his eyes.

MUSCULOSKELETAL: Denies any joint pain, swelling or tenderness.

LYMPHATICS: Complains of lymph nodes under his chin being swollen.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies excessive sweating, thirst, or urination.

ALLERGIES: Denies frequent or re-occuring infections.

Objective Data:

Physical exam:

Vital signs: BP 138/84, left arm, sitting, regular cuff; manual; P 91 and regular, T 36.7

Orally; RR 18 non-labored; Wt: 179 lbs; Ht: 6’1”; BMI: 23.6

General: A/Ox4 well groomed, dressed appropriately.

HEENT: PERRLA, normal conjunctivae, mucous membranes moist. Erythema noted to auditory canal and tympanic membrane bilaterally. Pale, boggy, nasal mucosa, and enlarged turbinates.

Neck: Supple, no JVD noted, no bruits. Symmetric, no abnormal findings.

Chest/Lungs: Clear to auscultation in all lung fields.

Cardiovascular: Regular rate and rhythm. No murmur, rub, or gallops noted.

Abdomen: BS positive X4 quadrants, non-tender, soft, round, no rebound tenderness or guarding noted.

Musculoskeletal: Well developed, no abnormal findings.

Neurological: A/O x4, calm and cooperative. Mood and affect are appropriate.

Skin: No rashes or abnormal findings.

Diagnostic results:

1.) Throat swab to r/o strep (Stefaniuk, Bosacka, Wanke-Rytt & Hryniewicz, 2017).

2.) Nasal swab to r/o COVID-19 (CDC, 2020.)

3.) Chest x-ray (Demarco, 2020.)

Assessment:

Primary Diagnosis:

Upper Respiratory Infection: Could be bacterial or viral. Symptoms include sore throat, nasal symptoms, and cough (Schroeck, et. al, 2015.)

Differential Diagnoses (DDx):

Sinusitis: Symptoms may include purulent nasal discharge, nasal obstruction, facial pain, pressure and/or fullness (Rosenfeld, 2016.)
Common Cold: Upper respiratory symptoms that can be caused by a variety of different pathogens. Symptoms include sore or scratchy throat, nasal obstruction, cough, nasal secretions, swollen and red nasal turbinates (Turner, 2015.)
Allergic Rhinitis: Symptoms include sneezing, nasal pruritus, airflow obstruction, and clear nasal discharge. Often caused by allergens like seasonal pollen, mold, dust mites, and pets (Wheatley & Togias, 2015.)
COVID-19: Symptoms can include fever, cough, fatigue, sputum production, headache, dyspnea, sore throat, and GI problems such as diarrhea, N/V (Rothan & Byrareddy, 2020.)
Strep Throat: Symptoms include sore throat, difficulty or painful swallowing, enlarged cervical lymph nodes, lack of cough, and fever (Thai, Dale & Ebell, 2018.)

Conclusion

HEENT symptoms can be caused by a variety of things. It’s important to assess the patient thoroughly in order to identify the reason and cause behind the symptoms the patient is experiencing. Upper respiratory infections can be viral or bacterial, and determining which one is important in order to move forward with the most appropriate treatment.

References

CDC. (2020, June 24). Testing for COVID-19. Retrieved July 2, 2020, from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html

Demarco, C. (2020, June 24). 10 things to know about COVID-19 testing. Retrieved July 3, 2020, from https://www.mdanderson.org/cancerwise/is-covid-19-coronavirus-testing-accurate-and-9-more-things-to-know-about-covid-19-nasal-swab-testing.h00-159381945.html

Rosenfeld, R. M. (2016). Acute sinusitis in adults. N Engl J Med, 375, 962-970.

Rothan, H. A., & Byrareddy, S. N. (2020). The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. Journal of autoimmunity, 102433.

Schroeck, J. L., Ruh, C. A., Sellick, J. A., Ott, M. C., Mattappallil, A., & Mergenhagen, K. A. (2015). Factors associated with antibiotic misuse in outpatient treatment for upper respiratory tract infections. Antimicrobial agents and chemotherapy, 59(7), 3848-3852.

Stefaniuk, E., Bosacka, K., Wanke-Rytt, M., & Hryniewicz, W. (2017). The use of rapid test QuikRead go® Strep A in bacterial pharyngotonsillitis diagnosing and therapeutic decisions. European Journal of Clinical Microbiology & Infectious Diseases, 36(10), 1733-1738.

Thai, T. N., Dale, A. P., & Ebell, M. H. (2018). Signs and symptoms of group A versus non-group A strep throat: a meta-analysis. Family practice, 35(3), 231-238.

Turner, R. B. (2015). The common cold. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 748.

Wheatley, L. M., & Togias, A. (2015). Allergic rhinitis. New England Journal of Medicine, 372(5), 456-463.

NURS 6512 Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat Instructions

Photo Credit: Getty Images/Blend Images

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.

NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat Soap Note

Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.

In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

To Prepare

By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.

With regard to the case study you were assigned:

Review this week’s Learning Resources and consider the insights they provide.
Consider what history would be necessary to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

By Day 6 of Week 5

Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK5Assgn1+last name+first initial.(extension)” as the name.
Click the Week 5 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
Click the Week 5 Assignment 1 You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer Find the document you saved as “WK5Assgn1+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submitbutton to complete your submission.

Assignment 2: Digital Clinical Experience: Focused Exam: Cough

In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

Photo Credit: Getty Images

To Prepare

Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Focused Exam: Cough Assignment:

Complete the following in Shadow Health:

Respiratory Concept Lab (Recommended but not required)
Episodic/Focused Note for Focused Exam: Cough

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.

Submission and Grading Information

By Day 7 of Week 5

Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Blackboard for your faculty review.
(Note:Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
Once you submit your Documentation Notes to Shadow Health, make sure to copy and paste the same Documentation Notes into your Assignment submission link below.
Download, sign, date, and submit your Student Acknowledgement Form found in the Learning Resources for this week.

Week 5 – Focused Exam: Cough, Danny Rivera – REQUIRED Results | Turned In

Experience Overview

Patient: Danny Rivera

Digital Clinical Experience Score

82.7%

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

31.07

out of

Proficiency Level:

Developing

Students rated as “developing” demonstrate increasing clinical reasoning abilities as they apply their knowledge of advanced practice competencies. In comparable programs, 25% of students perform at the level of a developing practitioner. Review your results in the tabs on the left side of the page to identify areas for improvement.

Subjective Data Collection

out of

Objective Data Collection

12.07

out of

Education and Empathy

out of

Time

101 minutes total spent in assignment

Interaction with patient

101 minutes

Transcript

Started: Dec 31, 2020 | Total Time: 101 min

All Lines (151)Interview Questions (58)Statements (10)Exam Actions (83)

	Hello	Greet 12/31/20 7:15 AM MST
	Hi.
	What is your name?	Question 12/31/20 7:15 AM MST
	My name is Daniel Rivera, but I just go by Danny.
	That’s awesome Danny. Sorry for the cough. My name is Mukabat and I will be assessing you today.	Empathize 12/31/20 7:16 AM MST
	Thank you.
	Allow me me to take some measurements for your vitals. (No matching questions found.)	Question 12/31/20 7:17 AM MST
	Checked vitals	Exam Action 12/31/20 7:17 AM MST
	So Danny, what brings you in today?	Question 12/31/20 7:20 AM MST
	My Abuela brought me here because I’ve been feeling sick. I have been coughing a lot. . . and I feel kinda tired.
	I am sorry that you have that cough and that you feel kind of tired. I will make sure we make you feel better soon.	Empathize 12/31/20 7:21 AM MST
	Thank you.
	When did the cough start?	Question 12/31/20 7:21 AM MST
	I think the cough started four. . . No, it started five days ago.
	Sorry that you have been coughing for the past five days.	Empathize 12/31/20 7:22 AM MST
	Thank you.
	Can you describe the cough	Question 12/31/20 7:22 AM MST
	I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
	Does anything relieve the cough	Question 12/31/20 7:22 AM MST
	I haven’t taken anything except the cough medicine my mom gave me. It helped a little, but then my cough started up again.
	What medicines do you usually take?	Question 12/31/20 7:23 AM MST
	I took some cough medicine this morning. [AUDIO COMING SOON]
	Do you play any sports?	Question 12/31/20 7:24 AM MST
	I don’t really play any sports on a team or anything. I like to shoot hoops and ride my skateboard with Tony sometimes. But most of the time we play video games.
	Do you have any discharge from the nose? (Clarified to Is your nose runny?.)	Question 12/31/20 7:24 AM MST
	My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think. (Clarified to if my nose is runny.)
	What is the color of the discharge?	Question 12/31/20 7:25 AM MST
	You mean like when I blow my nose? It’s clear.
	Do your have any pain in the ears?	Question 12/31/20 7:25 AM MST
	My right ear is starting to hurt a little bit . . . my left one is OK though.
	Does your throat hurt?	Question 12/31/20 7:26 AM MST
	It feels a little bit sore, yeah.
	Do you have any allergies?	Question 12/31/20 7:26 AM MST
	I don’t really have any allergies. Tony has some though. He’s allergic to bees.
	What is your family medical history?	Question 12/31/20 7:27 AM MST
	My mom sometimes talks about her diabetes, cholesterol. . . Oh, and blood pressure. Papi talks about cholesterol too. He smokes too. I know that’s bad.
	Are you always present when Papi smokes? (No matching questions found.)	Question 12/31/20 7:27 AM MST
	Do you have any difficulty breathing?	Question 12/31/20 7:28 AM MST
	I breathe OK.
	Do you feel any pain when swallowing?	Question 12/31/20 7:28 AM MST
	No, I can swallow OK. It hurts a little right now because my throat is kinda sore.
	Do you feel tired?	Question 12/31/20 7:29 AM MST
	Yeah, I feel kind of tired. I think it’s because I couldn’t sleep much at night. My cough kept me from falling asleep.
	Am sorry to hear that.	Empathize 12/31/20 7:29 AM MST
	Thank you.
	Lack of proper sleep can always make one feel tired during the day.	Educate 12/31/20 7:30 AM MST
	Oh, OK.
	Do you feel nauseated?	Question 12/31/20 7:30 AM MST
	No, I don’t feel nauseous.
	Did you take any medication this morning?	Question 12/31/20 7:30 AM MST
	I had some cough medicine this morning. [AUDIO COMING SOON]
	It always advisable that we know the medications you take.	Educate 12/31/20 7:31 AM MST
	Oh, OK.
	Do you have any problem buying medications?	Question 12/31/20 7:35 AM MST
	Ummmmm. I dunno. I don’t think so. [AUDIO COMING SOON]
	Does Papi smoke in the house?	Question 12/31/20 7:35 AM MST
	Yeah, sometimes Papi smokes cigars inside. He forgets to take them outside and my mom has to remind him. [AUDIO COMING SOON]
	It advisable that you stay away from Papi when he smokes. Smoke is not healthy for you.	Educate 12/31/20 7:36 AM MST
	Oh, OK.
	Performed otoscopic examination of right naris	Exam Action 12/31/20 7:37 AM MST
	Performed otoscopic examination of left naris	Exam Action 12/31/20 7:38 AM MST
	Performed otoscopic examination of right naris	Exam Action 12/31/20 7:38 AM MST
	Performed otoscopic examination of left ear	Exam Action 12/31/20 7:39 AM MST
	Performed otoscopic examination of right ear	Exam Action 12/31/20 7:39 AM MST
	Performed otoscopic examination of left ear	Exam Action 12/31/20 7:39 AM MST
	Performed otoscopic examination of right ear	Exam Action 12/31/20 7:40 AM MST
	Inspected mouth	Exam Action 12/31/20 7:41 AM MST
	Inspected front of neck	Exam Action 12/31/20 7:43 AM MST
	Inspected right side of neck	Exam Action 12/31/20 7:44 AM MST
	Inspected front of neck	Exam Action 12/31/20 7:44 AM MST
	Inspected left side of neck	Exam Action 12/31/20 7:44 AM MST
	Inspected front of neck	Exam Action 12/31/20 7:44 AM MST
	Inspected anterior chest wall	Exam Action 12/31/20 7:44 AM MST
	Palpated frontal sinuses: No tenderness reported	Exam Action 12/31/20 7:47 AM MST
	Palpated maxillary sinuses: No tenderness reported	Exam Action 12/31/20 7:47 AM MST
	Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side	Exam Action 12/31/20 7:48 AM MST
	Palpated supraclavicular lymph nodes: Not palpable	Exam Action 12/31/20 7:48 AM MST
	Palpated axillary lymph nodes: Not palpable	Exam Action 12/31/20 7:49 AM MST
	Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally	Exam Action 12/31/20 7:49 AM MST
	Ninety-nine.
	Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally	Exam Action 12/31/20 7:50 AM MST
	Ninety-nine.
	Palpated fremitus in posterior upper chest wall: Expected fremitus, equal bilaterally	Exam Action 12/31/20 7:50 AM MST
	Ninety-nine.
	Palpated fremitus in posterior middle chest wall: Expected fremitus, equal bilaterally	Exam Action 12/31/20 7:50 AM MST
	Ninety-nine.
	Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally	Exam Action 12/31/20 7:50 AM MST
	Ninety-nine.
	Auscultated breath sounds in anterior right upper lobe	Exam Action 12/31/20 7:50 AM MST
	Auscultated breath sounds in anterior left upper lobe	Exam Action 12/31/20 7:51 AM MST
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 12/31/20 7:51 AM MST
	Auscultated breath sounds in anterior right middle lobe	Exam Action 12/31/20 7:51 AM MST
	Auscultated breath sounds in anterior right middle lobe	Exam Action 12/31/20 7:51 AM MST
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 12/31/20 7:51 AM MST
	Auscultated breath sounds in anterior left lower lobe	Exam Action 12/31/20 7:51 AM MST
	Auscultated breath sounds in anterior right lower lobe	Exam Action 12/31/20 7:51 AM MST
	Auscultated breath sounds in posterior left upper lobe	Exam Action 12/31/20 7:51 AM MST
	Auscultated breath sounds in posterior right upper lobe	Exam Action 12/31/20 7:51 AM MST
	Auscultated breath sounds in posterior left mid-back (lower lobe)	Exam Action 12/31/20 7:52 AM MST
	Auscultated breath sounds in posterior right mid-back (lower lobe)	Exam Action 12/31/20 7:52 AM MST
	Auscultated breath sounds in posterior left lower lobe near spine	Exam Action 12/31/20 7:52 AM MST
	Auscultated breath sounds in posterior right lower lobe near spine	Exam Action 12/31/20 7:52 AM MST
	Auscultated breath sounds in posterior left lower lobe on side	Exam Action 12/31/20 7:52 AM MST
	Auscultated breath sounds in posterior left lower lobe	Exam Action 12/31/20 7:52 AM MST
	Auscultated breath sounds in posterior right lower lobe	Exam Action 12/31/20 7:52 AM MST
	Auscultated breath sounds in posterior right lower lobe on side	Exam Action 12/31/20 7:52 AM MST
	Auscultated voice sounds in anterior right upper lobe	Exam Action 12/31/20 7:53 AM MST
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in anterior left upper lobe	Exam Action 12/31/20 7:53 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in anterior right middle lobe	Exam Action 12/31/20 7:53 AM MST
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in anterior left mid-chest (upper lobe)	Exam Action 12/31/20 7:54 AM MST
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in anterior right middle lobe	Exam Action 12/31/20 7:54 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in anterior left mid-chest (upper lobe)	Exam Action 12/31/20 7:54 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in anterior right lower lobe	Exam Action 12/31/20 7:54 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in anterior left lower lobe	Exam Action 12/31/20 7:54 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in posterior left upper lobe	Exam Action 12/31/20 7:54 AM MST
	Ninety-nine.
	Auscultated voice sounds in posterior right upper lobe	Exam Action 12/31/20 7:54 AM MST
	Ninety-nine.
	Auscultated voice sounds in posterior left mid-back (lower lobe)	Exam Action 12/31/20 7:55 AM MST
	Ninety-nine.
	Auscultated voice sounds in posterior right mid-back (lower lobe)	Exam Action 12/31/20 7:55 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in posterior left lower lobe near spine	Exam Action 12/31/20 7:55 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in posterior right lower lobe near spine	Exam Action 12/31/20 7:55 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in posterior left lower lobe on side	Exam Action 12/31/20 7:55 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in posterior left lower lobe	Exam Action 12/31/20 7:55 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in posterior right lower lobe	Exam Action 12/31/20 7:55 AM MST
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in posterior right lower lobe on side	Exam Action 12/31/20 7:55 AM MST
	Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Auscultated aortic area with the bell	Exam Action 12/31/20 7:55 AM MST
	Auscultated pulmonic area with the bell	Exam Action 12/31/20 7:55 AM MST
	Auscultated Erb’s point with the bell	Exam Action 12/31/20 7:56 AM MST
	Auscultated tricuspid area with the bell	Exam Action 12/31/20 7:56 AM MST
	Auscultated mitral area with the bell	Exam Action 12/31/20 7:56 AM MST
	Percussed anterior right upper lobe	Exam Action 12/31/20 7:57 AM MST
	Percussed anterior left upper lobe	Exam Action 12/31/20 7:57 AM MST
	Percussed anterior right middle lobe	Exam Action 12/31/20 7:57 AM MST
	Percussed anterior left mid-chest (upper lobe)	Exam Action 12/31/20 7:57 AM MST
	Percussed anterior left lower lobe	Exam Action 12/31/20 7:57 AM MST
	Percussed anterior right lower lobe	Exam Action 12/31/20 7:57 AM MST
	Percussed posterior left upper lobe	Exam Action 12/31/20 7:57 AM MST
	Percussed posterior right upper lobe	Exam Action 12/31/20 7:57 AM MST
	Percussed posterior left mid-back (lower lobe)	Exam Action 12/31/20 7:57 AM MST
	Percussed posterior right mid-back (lower lobe)	Exam Action 12/31/20 7:57 AM MST
	Percussed posterior left lower lobe	Exam Action 12/31/20 7:57 AM MST
	Percussed posterior right lower lobe	Exam Action 12/31/20 7:57 AM MST
	Percussed posterior left lower lobe on side	Exam Action 12/31/20 7:57 AM MST
	Percussed posterior left lower lobe near spine	Exam Action 12/31/20 7:58 AM MST
	Percussed posterior right lower lobe near spine	Exam Action 12/31/20 7:58 AM MST
	Percussed posterior left right lobe on side	Exam Action 12/31/20 7:58 AM MST
	Have you been immunized?	Question 12/31/20 7:59 AM MST
	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.
	Sure you need them. Keep getting them. They keep you safe from infections.	Educate 12/31/20 7:59 AM MST
	Oh, OK.
	How many friends do you have? (Clarified to Do you have many friends?.)	Question 12/31/20 8:00 AM MST
	I have a lot of friends at school, but my best friend is Tony. We hang out all the time. (Clarified to if I have a lot of friends.)
	What is your diet like?	Question 12/31/20 8:01 AM MST
	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.
	Do you also exercise? (No matching questions found.)	Question 12/31/20 8:01 AM MST
	Does running make the cough worse? (Clarified to Does activity make your cough worse?.)	Question 12/31/20 8:02 AM MST
	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. (Clarified to if activity makes my cough worse.)
	Does the cough get better when you are seated? (Clarified to Does rest relieve your cough?.)	Question 12/31/20 8:03 AM MST
	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.)
	Do you smoke?	Question 12/31/20 8:03 AM MST
	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 use any other substance? (Clarified to Have you ever experimented with drugs?.)	Question 12/31/20 8:04 AM MST
	No way! (Clarified to if I have ever experimented with drugs.)
	Do you cough a lot at night?	Question 12/31/20 8:06 AM MST
	Yeah, my cough’s worse at night.
	So sorry to hear that.	Empathize 12/31/20 8:07 AM MST
	Thank you.
	have you been hospitalized before?	Question 12/31/20 8:07 AM MST
	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.
	Have you been treated for pneumonia in the past one year?	Question 12/31/20 8:08 AM MST
	I think I had that last year, when I was seven. My mom was really worried.
	Have you had any surgeries?	Question 12/31/20 8:08 AM MST
	I have never had a surgery. I don’t think I want to have one.
	What home medications do you us? (Clarified to What medications do you take?.)	Question 12/31/20 8:08 AM MST
	I took some cough medicine this morning. [AUDIO COMING SOON] (Clarified to what medications I am taking.)
	Checked vitals	Exam Action 12/31/20 8:09 AM MST
	What grade are you in?	Question 12/31/20 8:09 AM MST
	I’m in the 3rd grade, in Ms. Saint-Jean’s class.
	Did you miss some school days last year (Clarified to Do you miss school often?.)	Question 12/31/20 8:09 AM MST
	I haven’t stayed home for my cough, but sometimes when I’m really sick I get to stay home. (Clarified to if I miss school often.)
	What language do you use at home?	Question 12/31/20 8:10 AM MST
	We speak in English at home most of the time, but I know some words in Spanish!
	What is the frequency and duration of the cough?	Question 12/31/20 8:10 AM MST
	I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
	How many spoons of cough medicine did you take?	Question 12/31/20 8:14 AM MST
	I only took the cough medicine once. My mom gave me a spoonful. [AUDIO COMING SOON]
	Do you take any vitamins?	Question 12/31/20 8:14 AM MST
	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!
	Have you ever had an ear infection?	Question 12/31/20 8:15 AM MST
	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 asthma?	Question 12/31/20 8:15 AM MST
	Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don’t have to.
	Do you have frequent pneumonia? (Clarified to Tell me about your pneumonia?.)	Question 12/31/20 8:15 AM MST
	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. (Clarified to to tell you about my pneumonia.)
	Does your father have asthma?	Question 12/31/20 8:16 AM MST
	Mom says Papi had asthma when he was a little kid.
	Do you have frequent colds?	Question 12/31/20 8:17 AM MST
	I get colds a lot. My nose is always runny.
	Do you have chills?	Question 12/31/20 8:17 AM MST
	No, I haven’t felt that.
	Do you have fever?	Question 12/31/20 8:17 AM MST
	My mom said I didn’t have a fever this morning before Abuela took me here.
	Do you sweat at night?	Question 12/31/20 8:17 AM MST
	I don’t sweat at night unless it gets really hot or something.
	Do you have headaches?	Question 12/31/20 8:18 AM MST
	I don’t usually get headaches.
	Do you get nosebleeds?	Question 12/31/20 8:18 AM MST
	Just one time. Tony and I were kicking a ball at recess and I got hit in the nose.
	Do you have any vision difficulty?	Question 12/31/20 8:18 AM MST
	No, I see really good. Oh, I mean, I see well. I think glasses are kind of cool though. My friend Tony has them.
	Do you feel dizzy sometimes?	Question 12/31/20 8:19 AM MST
	I only get dizzy if I’m spinning around a lot at recess.
	Do you feel any sinus pain?	Question 12/31/20 8:19 AM MST
	It doesn’t hurt there.
	Do you experience red eyes? (No matching questions found.)	Question 12/31/20 8:20 AM MST
	Does your chest feel tight?	Question 12/31/20 8:21 AM MST
	My chest feels okay.
	Do you have any chest pains?	Question 12/31/20 8:21 AM MST
	No, I don’t have pain in my chest. I would hate that!
	Do you know what triggers your cough?	Question 12/31/20 8:22 AM MST
	I don’t know what makes me cough . . . I think it is just because I’m sick.
	Thank you Danny for visiting us today. I advise that you take a lot of fluids going forward. Also, make sure that you are not close to your father when he smokes. Always ensure that you wash your hands before eating anything, or use a hand sanitizer should water be unavailable. This way you will reduce your chances of catching an infection.	Educate 12/31/20 8:48 AM MST
	Oh, OK.

Subjective Data Collection: 17 of 21 (81.0%)

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)

Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

Do you have a cough?

History of Present Illness

Finding:

Asked about onset of cough

Finding:

Reports cough started 5 days ago

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How long have you had a cough?

Finding:

Asked about frequency and duration of cough

Finding:

Reports coughing every few minutes

(Found)

Example Question:

How frequently have you been coughing?

Finding:

Asked about character of cough

Finding:

Reports cough is wet

(Available)

Example Question:

Is your cough a wet cough?

Finding:

Reports clear sputum

(Available)

Example Question:

Do you produce any phlegm or sputum with your cough?

Finding:

Asked about aggravating factors for cough

Finding:

Reports cough is worse at night

(Found)

Example Question:

Is your cough worse at night?

Finding:

Reports exposure to secondhand smoke

(Found)

Example Question:

Are you around anyone who smokes at home?

Finding:

Denies knowing what makes the cough worse

(Found)

Example Question:

What makes your cough worse?

Finding:

Asked about relieving factors for cough

Finding:

Denies resting relieves cough

(Found)

Example Question:

Does resting help your cough?

Finding:

Denies drinking water relieves cough

(Available)

Example Question:

Does drinking water help your cough?

Finding:

Asked about nasal symptoms

Finding:

Reports current runny nose

(Found)

Example Question:

Do you have a runny nose?

Finding:

Denies sneezing

(Available)

Example Question:

Have you been sneezing?

Finding:

Reports frequent runny nose

(Found)

Example Question:

Do you get runny noses often?

Finding:

Followed up on nasal discharge

Finding:

Reports nasal discharge is clear

(Found)

Example Question:

What color is your snot?

Finding:

Reports nasal discharge is thin

(Found)

Example Question:

Is your snot thin?

Finding:

Asked about ear symptoms

Finding:

Reports pain in right ear

(Found)

Example Question:

Do you have any ear pain?

Finding:

Followed up on ear pain

Finding:

Reports ear pain started yesterday

(Available)

Example Question:

How long have you had ear pain?

Finding:

Reports ear pain is a 3 out of 10

(Available)

Example Question:

Can you rate your ear pain on a scale?

Finding:

Denies ear discharge

(Available)

Example Question:

Do you have any ear discharge?

Finding:

Asked about throat symptoms

Finding:

Reports sore throat

(Found)

Example Question:

Is your throat sore?

Finding:

Reports “a little” pain with swallowing

(Found)

Example Question:

Does it hurt when you swallow?

Finding:

Asked about allergies

Finding:

Denies seasonal allergies

(Available)

Example Question:

Do you have seasonal allergies?

Finding:

Denies food allergies

(Available)

Example Question:

Do you have food allergies?

Finding:

Denies medication allergies

(Available)

Example Question:

Are you allergic to any medicine?

Finding:

Denies allergies to animals

(Available)

Example Question:

Are you allergic to animals?

Finding:

Denies latex allergy

(Available)

Example Question:

Are you allergic to latex?

Finding:

Asked about contact with illnesses

Finding:

Denies being around anyone ill at home

(Available)

Example Question:

Is anyone sick at home?

Home Medications

Finding:

Asked about home medications

Finding:

Confirmed home medications

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What medications do you take?

Finding:

Reports taking a daily vitamin

(Found)

Example Question:

Do you take vitamins?

Finding:

Reports taking cough medicine

(Found)

Example Question:

Are you taking medication for your cough?

Finding:

Followed up on cough medicine

Finding:

Reports cough medicine was purple

(Available)

Example Question:

What color was the cough medicine?

Finding:

Reports taking one spoonful of cough medicine

(Found)

Example Question:

How much cough medicine did you take?

Finding:

Reports mother gave him the medicine

(Found)

Example Question:

Who gave you the cough medicine?

Finding:

Reports cough medicine provided temporary relief

(Found)

Example Question:

Did the cough medicine make you feel better?

Past Medical History

Finding:

Asked about relevant medical history

Finding:

Denies asthma diagnosis

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have asthma?

Finding:

Reports immunizations as current

(Found)

Example Question:

Do you have current immunizations?

Finding:

Reports past pneumonia and frequent coughs

(Found)

Example Question:

Do you have a history of respiratory problems?

Finding:

Denies past hospitalizations

(Found)

Example Question:

Have you ever been to the hospital?

Social Determinants of Health

Finding:

Asked about exposure to secondhand smoke

Finding:

Reports father smokes cigars

(Found)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

Who smokes at home?

Finding:

Reports father sometimes forgets to take cigars outside

(Found)

Example Question:

Where does your father smoke?

Social History

Finding:

Asked about living conditions

Finding:

Reports living in a house with parents and grandparents

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Where do you live?

Finding:

Reports feeling safe at home

(Available)

Example Question:

Do you feel safe at home?

Finding:

Reports park with playground near home

(Available)

Example Question:

Is there anywhere near your home where you can play outside?

Review of Systems

Finding:

Asked about constitutional health

Finding:

Denies fever

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have a fever?

Finding:

Denies chills

(Found)

Example Question:

Do you have chills?

Finding:

Reports feeling “kind of tired”

(Found)

Example Question:

Do you have fatigue?

Finding:

Denies night sweats

(Found)

Example Question:

Do you have night sweats?

Finding:

Denies weight loss

(Available)

Example Question:

Has your weight changed?

Finding:

Denies appetite loss

(Available)

Example Question:

Have you lost your appetite?

Finding:

Asked about review of systems for HEENT

Finding:

Denies ear popping or crackling

(Available)

Example Question:

Do you hear any popping sounds?

Finding:

Reports history of frequent ear infections

(Found)

Example Question:

Have you ever had ear infections?

Finding:

Denies ear surgery or ear tubes

(Available)

Example Question:

Have you ever had surgery on your ears?

Finding:

Denies headaches

(Found)

Example Question:

Do you get headaches?

Finding:

Denies nosebleeds

(Found)

Example Question:

Do you have nosebleeds?

Finding:

Denies vision problems

(Found)

Example Question:

Do you have any problems with your vision?

Finding:

Denies dizziness

(Found)

Example Question:

Do you have any dizziness?

Finding:

Denies watery eyes

(Available)

Example Question:

Do you have watery eyes?

Finding:

Denies eye redness

(Available)

Example Question:

Do you have eye redness?

Finding:

Denies eye pain

(Available)

Example Question:

Do you have any eye pain?

Finding:

Denies sinus pain

(Found)

Example Question:

Do you have any sinus pain?

Finding:

Denies hearing problems

(Available)

Example Question:

Do you have any hearing problems?

Finding:

Asked about review of systems for respiratory

Finding:

Denies difficulty breathing

(Found)

Example Question:

Do you have difficulty breathing?

Finding:

Denies chest tightness

(Found)

Example Question:

Do you have chest tightness?

Finding:

Denies chest pain

(Found)

Example Question:

Do you have any chest pain?

Finding:

Denies history of inhaler use or breathing treatments

(Available)

Example Question:

Have you ever used an inhaler?

Comments

Lab Pass

Objective Data Collection: 12.07 of 13 (92.85%)

Correct
Partially correct

Incorrect
Missed

Inspected eyes and orbital area

1 of 1 point

Orbital Area (1/4 point)

No visible abnormal findings
Ptosis
Eyelid edema
Lesion
Allergic shiners

Sclera (1/4 point)

White
Jaundice
Injection
Icterus

Conjunctiva (1/4 point)

Moist and pink
Pale
Dry appearance
Erythema
Edema

Conjunctival Discharge (1/4 point)

No discharge
Clear, watery discharge
Purulent discharge

Inspected nasal cavities

1 of 1 point

Color (1/4 point)

Pink
Erythemic
Bluish

Discharge (1/4 point)

No discharge
Clear discharge
Bloody discharge
Purulent discharge

Turbinate Patency (1/4 point)

Patent
Decreased patency
Not patent

Observations (1/4 point)

No additional visible abnormal findings
Foreign body present
Polyp
Septum perforated
Septum deviated
Lesion

Inspected ears

0.8 of 1 point

Right: Auditory Canal Color (No point)

Pink
Erythemic
Pallor

Right: Tympanic Membrane Color (No point)

Pearly gray
Erythemic
Opaque
Yellow
Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 point)

No visible abnormal findings
Fluid observed
Visible scars
Bulging
Perforation
Retraction

Right: Cone Of Light (1/10 point)

5:00
Cone of light distorted

Right: Discharge (1/10 point)

No discharge
Cerumen
Clear discharge
Bloody discharge
Purulent discharge

Left: Auditory Canal Color (1/10 point)

Pink
Erythemic
Pallor

Left: Tympanic Membrane Color (1/10 point)

Pearly gray
Erythemic
Opaque
Yellow
Not visible because of cerumen

Left: Tympanic Membrane Appearance (1/10 point)

No visible abnormal findings
Fluid observed
Visible scars
Bulging
Perforation
Retraction

Left: Cone Of Light (1/10 point)

7:00
Cone of light distorted

Left: Discharge (1/10 point)

No discharge
Cerumen
Clear discharge
Bloody discharge
Purulent discharge

Inspected mouth and throat

0.6 of 1 point

Oral Mucosa (1/5 point)

Moist and pink
Dry appearance
Erythema

Tonsils (No point)

No visible abnormal findings
Edema
Erythema

Posterior Oropharynx Color (No point)

Pink
Erythemic

Posterior Oropharynx Texture (1/5 point)

No abnormal findings
Cobblestoning
Exudate

Post Nasal Drip (1/5 point)

No discharge
Clear discharge
Purulent discharge

Inspected neck

1 of 1 point

Symmetry (1/2 point)

Symmetric
Asymmetric

Appearance (1/2 point)

No visible abnormal findings
Swelling
Visible pulsation
Visible mass
Discoloration

Inspected chest

1 of 1 point

Symmetry (1/2 point)

Symmetric
Asymmetric

Appearance (1/2 point)

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)

Palpated sinuses

1 of 1 point

Frontal (1/2 point)

None reported
Tenderness reported

Maxillary (1/2 point)

None reported
Tenderness reported

Palpated lymph nodes

0.67 of 1 point

Cervical (No point)

No palpable nodes
Palpable nodes on right side
Palpable nodes on left side

Supraclavicular (1/3 point)

No palpable nodes
Palpable nodes on right side
Palpable nodes on left side 88888

Axillary (1/3 point)

No palpable nodes
Palpable nodes on right side
Palpable nodes on left side

Palpated fremitus

1 of 1 point

Symmetry (1/2 point)

Equal bilaterally
Unequal bilaterally

Vibration (1/2 point)

Expected fremitus
Decreased fremitus

Auscultated breath sounds

1 of 1 point

Breath Sounds (1/3 point)

Present in all areas
Diminished in some areas
Absent in some areas

Adventitious Sounds (1/3 point)

No adventitious sounds
Wheezing
Fine crackles
Stridor
Rhonchi
Rales

Location (1/3 point)

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

Auscultated for bronchophony

1 of 1 point

Bronchophony (1/1 point)

Positive
Negative

Auscultated heart sounds

1 of 1 point

Heart Sounds (1/2 point)

S1 and S2 audible
S1, S2, and S3 audible
S1, S2, and S4 audible
S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

No extra sounds
Gallops
Murmur
Friction rub
Valve clicks

Percussed chest wall

1 of 1 point

Observations (1/2 point)

All areas resonant
Some areas dull, some resonant
Some areas hyperresonant, some resonant

Location (1/2 point)

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 : 2 of 5 (40.0%)

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

1 Symptoms

Followed Up

	Description: Danny describes the symptoms that have been bothering him.
	Do you know what triggers your cough?	Question 08:22 AM MST
	I don’t know what makes me cough . . . I think it is just because I’m sick.
	Thank you Danny for visiting us today. I advise that you take a lot of fluids going forward. Also, make sure that you are not close to your father when he smokes. Always ensure that you wash your hands before eating anything, or use a hand sanitizer should water be unavailable. This way you will reduce your chances of catching an infection.	Educate 08:48 AM MST
	Oh, OK.
	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.”

2 Medications

Followed Up

	Description: Danny describes the medication he was given for his cough.
	Did you take any medication this morning?	Question 07:30 AM MST
	I had some cough medicine this morning. [AUDIO COMING SOON]
	It always advisable that we know the medications you take.	Educate 07:31 AM MST
	Oh, OK.
	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.”

3 Vitamins

Not Followed Up

	Description: Danny describes taking vitamins.
	Do you take any vitamins?	Question 08:14 AM MST
	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!
	Have you ever had an ear infection?	Question 08:15 AM MST
	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.”

4 Secondhand Smoke

Not Followed Up

	Description: Danny describes exposure to secondhand smoke at home.
	Do you smoke?	Question 08:03 AM MST
	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 use any other substance? (Clarified to: Have you ever experimented with drugs?)	Question 08:04 AM MST
	No way! (Clarified to: if I have ever experimented with drugs)
	Do you cough a lot at night?	Question 08:06 AM MST
	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.”

5 Family History

Not Followed Up

	Description: Danny describes what he knows about his family health history.
	Does your father have asthma?	Question 08:16 AM MST
	Mom says Papi had asthma when he was a little kid.
	Do you have frequent colds?	Question 08:17 AM MST
	Model Statement: “Thanks for telling me what you know about your family history. You did a good job remembering.”

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation	Model Documentation
Subjective Danny Rivera is a pleasant 8 year old patient of Pueto Rican decent presenting to the hospital with a cough he describes as ‘watery and gurgly’. He reports that he cough gets worse at night and keeps him awake, whic makes him feel tired by day. He reports pain in the left year as well as mild soreness in the throat. He reports that the mother gave him some over the counter cough medicine to help relieve his sore throat, although this did not help much. He reports experiencing frequent colds and runny nose, and that he had a frequent ear infection as a child.	N/A
Objective General Survey: Showing fatigue despite appearing stable. HEENT: Moist Mucus Membranes, clear nosal discharge. Cobblestones in the back of the throat. Dull eyes, pink conjuctiva. Cardiovascular: S1, S2, no murmurs. Respiratory: Increased respiratory but with no acute distress. Breath is clear to auscultation. Negative Bronchophony. Fremitus expected, equal bilaterally. Patient able to speak comfortably and in fiull sentences.	N/A
Assessment Danny is at risk for infection. While a cough is often unpleasant, it can be a symptom of something more alarming, such as the immune system being at risk of an infection. The patient should focus on maintaining respiratory hygiene.	N/A
Plan The short term goal for this patient should be to focus on respiratory hygiene, more so handwashing. Further, Further, the family should ensure that Danny is not exposed to smoke sincehis father smokes. Keeping the house smoke-free to minize exposure to environmental pathogens is a key goal for this family.	N/A

What’s Coming Up in Week 6?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

Next week, you will evaluate abnormal findings in the area of the abdomen and the gastrointestinal system. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system as you complete your Lab Assignment in assessing the abdomen in a SOAP note format. You will also take your Midterm Exam, which covers the topics in Weeks 1–6. Please review the previous weekly content and resources to help you prepare for your exam. Plan your time accordingly.

Week 6 Required Media

Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images

Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Lab Assignment. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Assignment on time.

Next Week

To go to the next week:

Week 6