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,6/4/2018 Focused Exam: Cough | Completed | Shadow Health
Focused Exam: Cough Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Overview
Transcript
Transcript
Started: Jun 04, 2018 | Patient Exam Time: 86 min
Subjective Data Collection
All Lines (180) Interview Questions (76) Statements (8) Exam Actions (96)
Objective Data Collection
Greet
Education & Empathy Hello, My name is Sara an FNP student and I will be interviewing you
06/04/18 2:50 PM
today
CDT
Documentation
Self-Reflection
Hi.
Question
What brought you into the clinic today? 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.
Question
What is your name? 06/04/18 2:52 PM
CDT
My name is Daniel Rivera, but I just go by Danny.
Question
And how old are you? 06/04/18 2:52 PM
CDT
I'm eight.
Question
What is your date of birth? 06/04/18 2:52 PM
CDT
I was born March 4th in, um . . . [Danny reports correct birth year.]
[AUDIO COMING SOON]
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, 6/4/2018 Focused Exam: Cough | Completed | Shadow Health
I'm sorry you feel so bad Empathize
06/04/18 2:54 PM
CDT
Thank you.
Question
When did your cough start? 06/04/18 2:55 PM
CDT
I think the cough started four. . . No, it started five days ago.
Question
Can you describe your place to me? 06/04/18 2:55 PM
CDT
My cough seems kind of gurgly and watery.
Question
Do you have any sputum? 06/04/18 2:56 PM
CDT
Is that the gross, slimy stuff? Yeah, I've been coughing some of that
up. It's not any strange color, though. It's just clear.
Question
How often are you coughing? 06/04/18 2:59 PM
CDT
I just keep feeling like I have to cough every couple minutes or so. I
think it gets worse at night.
Question
How long does a cough last? 06/04/18 2:59 PM
CDT
I think the cough started four. . . No, it started five days ago.
Question
What is the duration of your cough? (Clarified to How would you
06/04/18 3:00 PM
describe your cough?.)
CDT
My cough seems kind of gurgly and watery.
Question
What makes your cough worse? 06/04/18 3:00 PM
CDT
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