Week 5 – Focused Exam Cough Danny Rivera

Week 5 – Focused Exam Cough Danny Rivera

Week 5 – Focused Exam Cough Danny Rivera

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

Experience Overview

Patient: Danny Rivera

Digital Clinical Experience Score

Week 5 - Focused Exam Cough Danny Rivera

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

39

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

17 

out of

21

Objective Data Collection

12.07 

out of

13

Education and Empathy

out of

5

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. Week 5 – Focused Exam Cough Danny Rivera
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. Week 5 – Focused Exam Cough Danny Rivera 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. Week 5 – Focused Exam Cough Danny Rivera 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.) Week 5 – Focused Exam Cough Danny Rivera
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. Week 5 – Focused Exam Cough Danny Rivera
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)

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. Week 5 – Focused Exam Cough Danny Rivera

Example Question:

How frequently have you been coughing?

Finding:

Asked about character of cough

Finding:

Reports cough is wet

(Available)

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:

Is your cough a wet cough?

Finding:

Reports clear sputum

(Available)

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:

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)

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:

Is your cough worse at night?

Finding:

Reports exposure to secondhand smoke

(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:

Are you around anyone who smokes at home?

Finding:

Denies knowing what makes the cough worse

(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:

What makes your cough worse?

Finding:

Asked about relieving factors for cough

Finding:

Denies resting relieves cough

(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:

Does resting help your cough?

Finding:

Denies drinking water relieves cough

(Available)

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. Week 5 – Focused Exam Cough Danny Rivera

Example Question:

Does drinking water help your cough?

Finding:

Asked about nasal symptoms

Finding:

Reports current runny nose

(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:

Do you have a runny nose?

Finding:

Denies sneezing

(Available)

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:

Have you been sneezing?

Finding:

Reports frequent runny nose

(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:

Do you get runny noses often?

Finding:

Followed up on nasal discharge

Finding:

Reports nasal discharge is clear

(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. Week 5 – Focused Exam Cough Danny Rivera

Example Question:

What color is your snot?

Finding:

Reports nasal discharge is thin

(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:

Is your snot thin?

Finding:

Asked about ear symptoms

Finding:

Reports pain in right ear

(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:

Do you have any ear pain?

Finding:

Followed up on ear pain

Finding:

Reports ear pain started yesterday

(Available)

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 ear pain?

Finding:

Reports ear pain is a 3 out of 10

(Available)

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:

Can you rate your ear pain on a scale?

Finding:

Denies ear discharge

(Available)

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:

Do you have any ear discharge?

Finding:

Asked about throat symptoms

Finding:

Reports sore throat

(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:

Is your throat sore?

Finding:

Reports “a little” pain with swallowing

(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. Week 5 – Focused Exam Cough Danny Rivera

Example Question:

Does it hurt when you swallow?

Finding:

Asked about allergies

Finding:

Denies seasonal allergies

(Available)

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:

Do you have seasonal allergies?

Finding:

Denies food allergies

(Available)

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:

Do you have food allergies?

Finding:

Denies medication allergies

(Available)

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:

Are you allergic to any medicine?

Finding:

Denies allergies to animals

(Available)

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:

Are you allergic to animals?

Finding:

Denies latex allergy

(Available)

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:

Are you allergic to latex?

Finding:

Asked about contact with illnesses

Finding:

Denies being around anyone ill at home

(Available)

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:

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)

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:

Do you take vitamins?

Finding:

Reports taking cough medicine

(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:

Are you taking medication for your cough?

Finding:

Followed up on cough medicine

Finding:

Reports cough medicine was purple

(Available)

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 color was the cough medicine?

Finding:

Reports taking one spoonful of cough medicine

(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:

How much cough medicine did you take?

Finding:

Reports mother gave him the medicine

(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:

Who gave you the cough medicine?

Finding:

Reports cough medicine provided temporary relief

(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:

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)

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 current immunizations?

Finding:

Reports past pneumonia and frequent coughs

(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 a history of respiratory problems?

Finding:

Denies past hospitalizations

(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:

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. Week 5 – Focused Exam Cough Danny Rivera

Example Question:

Who smokes at home?

Finding:

Reports father sometimes forgets to take cigars outside

(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:

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)

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:

Do you feel safe at home?

Finding:

Reports park with playground near home

(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:

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. Week 5 – Focused Exam Cough Danny Rivera

Example Question:

Do you have a fever?

Finding:

Denies chills

(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 chills?

Finding:

Reports feeling “kind of tired”

(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 fatigue?

Finding:

Denies night sweats

(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 night sweats?

Finding:

Denies weight loss

(Available)

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:

Has your weight changed?

Finding:

Denies appetite loss

(Available)

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:

Have you lost your appetite?

Finding:

Asked about review of systems for HEENT

Finding:

Denies ear popping or crackling

(Available)

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 hear any popping sounds?

Finding:

Reports history of frequent ear infections

(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:

Have you ever had ear infections?

Finding:

Denies ear surgery or ear tubes

(Available)

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. Week 5 – Focused Exam Cough Danny Rivera

Example Question:

Have you ever had surgery on your ears?

Finding:

Denies headaches

(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 get headaches?

Finding:

Denies nosebleeds

(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 nosebleeds?

Finding:

Denies vision problems

(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 any problems with your vision?

Finding:

Denies dizziness

(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 any dizziness?

Finding:

Denies watery eyes

(Available)

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 watery eyes?

Finding:

Denies eye redness

(Available)

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 eye redness?

Finding:

Denies eye pain

(Available)

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 any eye pain?

Finding:

Denies sinus pain

(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 any sinus pain?

Finding:

Denies hearing problems

(Available)

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 any hearing problems?

Finding:

Asked about review of systems for respiratory

Finding:

Denies difficulty breathing

(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 difficulty breathing?

Finding:

Denies chest tightness

(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 chest tightness?

Finding:

Denies chest pain

(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. Week 5 – Focused Exam Cough Danny Rivera

Example Question:

Do you have any chest pain?

Finding:

Denies history of inhaler use or breathing treatments

(Available)

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:

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) Week 5 – Focused Exam Cough Danny Rivera

  •  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%) Week 5 – Focused Exam Cough Danny Rivera

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
SubjectiveDanny 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
ObjectiveGeneral 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. Week 5 – Focused Exam Cough Danny Rivera N/A
AssessmentDanny 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
PlanThe 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