Case NR 509

Focused Exam: Cough Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Lab Pass Transcript Started: Jun 04, 2018 | Patient Exam Time: 86 min All Lines (180) Interview Questions (76) Statements (8) Exam Actions (96) Hello, My name is Sara an FNP student and I will be interviewing you today Hi. What brought you into the clinic today? Greet 06/04/18 2:50 PM CDT Question 06/04/18 2:51 PM CDT My Abuela brought me here because I've been feeling sick. I have been coughing a lot. . . and I feel kinda tired. What is your name? Question 06/04/18 2:52 PM CDT My name is Daniel Rivera, but I just go by Danny. And how old are you? Question 06/04/18 2:52 PM CDT I'm eight. What is your date of birth? Question 06/04/18 2:52 PM CDT I was born March 4th in, um . . . [Danny reports correct birth year.] [AUDIO COMING SOON] Empathize 06/04/18 2:54 PM CDT Question 06/04/18 2:55 PM CDT Question 06/04/18 2:55 PM CDT Question 06/04/18 2:56 PM CDT Question 06/04/18 2:59 PM CDT Question 06/04/18 2:59 PM CDT Question 06/04/18 3:00 PM CDT Question 06/04/18 3:00 PM CDT Question 06/04/18 3:01 PM CDT Question 06/04/18 3:01 PM CDT Question 06/04/18 3:01 PM CDT Question 06/04/18 3:02 PM CDT Question 06/04/18 3:02 PM CDT Question 06/04/18 3:03 PM CDT Educate 06/04/18 3:03 PM CDT Question 06/04/18 3:04 PM CDT Question 06/04/18 3:04 PM CDT Question 06/04/18 3:05 PM CDT Question 06/04/18 3:05 PM CDT Question 06/04/18 3:05 PM CDT Question 06/04/18 3:05 PM CDT Question 06/04/18 3:06 PM CDT Question 06/04/18 3:08 PM CDT Question 06/04/18 3:08 PM CDT Educate 06/04/18 3:10 PM CDT Question 06/04/18 3:10 PM CDT Question 06/04/18 3:11 PM CDT Question 06/04/18 3:11 PM CDT Question 06/04/18 3:11 PM CDT Question 06/04/18 3:11 PM CDT Question 06/04/18 3:12 PM CDT Question 06/04/18 3:12 PM CDT Question 06/04/18 3:12 PM CDT Question 06/04/18 3:13 PM CDT Educate 06/04/18 3:14 PM CDT Question 06/04/18 3:14 PM CDT Question 06/04/18 3:14 PM CDT Question 06/04/18 3:14 PM CDT Question 06/04/18 3:15 PM CDT Question 06/04/18 3:15 PM CDT Question 06/04/18 3:15 PM CDT Question 06/04/18 3:16 PM CDT Question 06/04/18 3:16 PM CDT Empathize 06/04/18 3:17 PM CDT Question 06/04/18 3:17 PM CDT Question 06/04/18 3:18 PM CDT Question 06/04/18 3:18 PM CDT Empathize 06/04/18 3:18 PM CDT Question 06/04/18 3:18 PM CDT Question 06/04/18 3:19 PM CDT Question 06/04/18 3:20 PM CDT Question 06/04/18 3:20 PM CDT Empathize 06/04/18 3:21 PM CDT Question 06/04/18 3:21 PM CDT Question 06/04/18 3:21 PM CDT Question 06/04/18 3:21 PM CDT Question 06/04/18 3:22 PM CDT Question 06/04/18 3:23 PM CDT Question 06/04/18 3:23 PM CDT Question 06/04/18 3:23 PM CDT Question 06/04/18 3:24 PM CDT Question 06/04/18 3:25 PM CDT Question 06/04/18 3:26 PM CDT Educate 06/04/18 3:26 PM CDT Question 06/04/18 3:28 PM CDT Question 06/04/18 3:28 PM CDT Question 06/04/18 3:29 PM CDT Checked vitals Tested lung capacity with spirometer: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%) Inspected left orbital area and sclera Inspected right orbital area and sclera Inspected upper conjunctiva Inspected lower conjunctiva Performed otoscopic examination of left naris Performed otoscopic examination of right naris Performed otoscopic examination of left ear Performed otoscopic examination of right ear Performed otoscopic examination of left ear Performed otoscopic examination of right ear Performed otoscopic examination of left ear Exam Action 06/04/18 3:35 PM CDT Exam Action 06/04/18 3:40 PM CDT Exam Action 06/04/18 3:44 PM CDT Exam Action 06/04/18 3:44 PM CDT Exam Action 06/04/18 3:44 PM CDT Exam Action 06/04/18 3:44 PM CDT Exam Action 06/04/18 3:45 PM CDT Exam Action 06/04/18 3:45 PM CDT Exam Action 06/04/18 3:45 PM CDT Exam Action 06/04/18 3:46 PM CDT Exam Action 06/04/18 3:46 PM CDT Exam Action 06/04/18 3:46 PM CDT Exam Action 06/04/18 3:46 PM CDT Inspected mouth Inspected front of neck Inspected left side of neck Inspected back of neck Inspected right side of neck Inspected front of neck Inspected mouth Inspected mouth Inspected anterior chest wall Inspected posterior chest wall Inspected anterior chest wall Palpated frontal sinuses: No tenderness reported Palpated maxillary sinuses: No tenderness reported Exam Action 06/04/18 3:47 PM CDT Exam Action 06/04/18 3:48 PM CDT Exam Action 06/04/18 3:48 PM CDT Exam Action 06/04/18 3:48 PM CDT Exam Action 06/04/18 3:48 PM CDT Exam Action 06/04/18 3:48 PM CDT Exam Action 06/04/18 3:48 PM CDT Exam Action 06/04/18 3:48 PM CDT Exam Action 06/04/18 3:49 PM CDT Exam Action 06/04/18 3:49 PM CDT Exam Action 06/04/18 3:49 PM CDT Exam Action 06/04/18 3:49 PM CDT Exam Action 06/04/18 3:49 PM CDT Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side Palpated supraclavicular lymph nodes: Not palpable Palpated axillary lymph nodes: Not palpable Palpated axillary lymph nodes: Not palpable Palpated axillary lymph nodes: Not palpable Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally Auscultated breath sounds in anterior left upper lobe Auscultated breath sounds in anterior right upper lobe Auscultated breath sounds in anterior right middle lobe Auscultated breath sounds in anterior left mid-chest (upper lobe) Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 06/04/18 3:51 PM CDT Exam Action 06/04/18 3:51 PM CDT Exam Action 06/04/18 3:51 PM CDT Exam Action 06/04/18 3:51 PM CDT Exam Action 06/04/18 3:51 PM CDT Exam Action 06/04/18 3:53 PM CDT Exam Action 06/04/18 3:53 PM CDT Exam Action 06/04/18 3:53 PM CDT Exam Action 06/04/18 3:53 PM CDT Exam Action 06/04/18 3:53 PM CDT Exam Action 06/04/18 3:53 PM CDT Exam Action 06/04/18 3:53 PM CDT Auscultated breath sounds in anterior right middle lobe Auscultated breath sounds in anterior left lower lobe Auscultated breath sounds in anterior right lower lobe Auscultated breath sounds in posterior left upper lobe Auscultated breath sounds in posterior right upper lobe Auscultated breath sounds in posterior right mid-back (lower lobe) Auscultated breath sounds in posterior left mid-back (lower lobe) Auscultated breath sounds in posterior left lower lobe near spine Auscultated breath sounds in posterior right lower lobe near spine Auscultated breath sounds in posterior right lower lobe on side Auscultated breath sounds in posterior right lower lobe Auscultated breath sounds in posterior left lower lobe Auscultated breath sounds in posterior left lower lobe on side Exam Action 06/04/18 3:53 PM CDT Exam Action 06/04/18 3:53 PM CDT Exam Action 06/04/18 3:53 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Auscultated voice sounds in anterior left upper lobe Auscultated voice sounds in anterior right upper lobe Auscultated voice sounds in anterior right middle lobe Auscultated voice sounds in anterior left mid-chest (upper lobe) Auscultated voice sounds in anterior left mid-chest (upper lobe) Auscultated voice sounds in anterior right middle lobe Auscultated voice sounds in anterior right lower lobe Auscultated voice sounds in anterior left lower lobe Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:54 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Auscultated voice sounds in posterior left upper lobe Auscultated voice sounds in posterior right upper lobe Auscultated voice sounds in posterior right mid-back (lower lobe) Auscultated voice sounds in posterior left mid-back (lower lobe) Auscultated voice sounds in posterior left lower lobe near spine Auscultated voice sounds in posterior right lower lobe on side Auscultated voice sounds in posterior right lower lobe Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Auscultated voice sounds in posterior left lower lobe Auscultated voice sounds in posterior left lower lobe on side Auscultated voice sounds in posterior right lower lobe near spine Auscultated aortic area with the bell Auscultated aortic area with the diaphragm Auscultated pulmonic area with the diaphragm Auscultated pulmonic area with the bell Auscultated Erb's point with the bell Auscultated Erb's point with the diaphragm Auscultated tricuspid area with the diaphragm Auscultated tricuspid area with the bell Auscultated mitral area with the bell Auscultated mitral area with the diaphragm Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:55 PM CDT Exam Action 06/04/18 3:56 PM CDT Exam Action 06/04/18 3:56 PM CDT Exam Action 06/04/18 3:56 PM CDT Exam Action 06/04/18 3:56 PM CDT Exam Action 06/04/18 3:56 PM CDT Exam Action 06/04/18 3:56 PM CDT Exam Action 06/04/18 3:56 PM CDT Exam Action 06/04/18 3:56 PM CDT Exam Action 06/04/18 3:56 PM CDT Percussed anterior right upper lobe Percussed anterior left upper lobe Percussed anterior left mid-chest (upper lobe) Percussed anterior right middle lobe Percussed anterior right lower lobe Percussed anterior left lower lobe Percussed posterior left upper lobe Percussed posterior right upper lobe Percussed posterior left mid-back (lower lobe) Percussed posterior right mid-back (lower lobe) Percussed posterior left lower lobe Percussed posterior right lower lobe Percussed posterior left right lobe on side Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Percussed posterior right lower lobe near spine Percussed posterior left lower lobe near spine Percussed posterior left lower lobe on side Percussed posterior left lower lobe on side Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:57 PM CDT Exam Action 06/04/18 3:58 PM CDT Question 06/04/18 4:00 PM CDT Question 06/04/18 4:00 PM CDT Question 06/04/18 4:01 PM CDT Question 06/04/18 4:02 PM CDT Question 06/04/18 4:02 PM CDT ...................................CONTINUED........................