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Exam (elaborations)

Shadow Health Focused Exam COUGH Danny Rivera Digital Clinical Experience Score 100% Student Performance Index 34 out of 34

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Objective Data Collection 15 out of 15 Subjective Data Collection: 19 of 19 (100.0%) 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: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source. Example Question: Do you have a cough? History of Presenting Illness • Finding: Asked about onset of cough • Finding: Reports cough started 3 days ago (Found) Pro Tip: Whenever you are assessing a symptom or a health condition, in this case the patient's cough, inquiring about onset assesses the severity and the progression of the problem. Example Question: How long have you had a cough? • Finding: Asked about characteristics of cough • Finding: Reports cough is wet (Available) Pro Tip: The characteristics of a cough, such as whether it is dry or wet, can indicate key information about the type of illness the patient has. Example Question: Is your cough a wet cough? • Finding: Reports clear sputum with cough (Found) Pro Tip: The characteristics of a cough, such as whether it is productive, can indicate key information about the type of illness the patient has. Example Question: Do you produce any phlegm or sputum with your cough? • Finding: Asked about frequency and duration of cough • Finding: Reports coughing every few minutes (Found) Pro Tip: Establishing how frequently Danny coughs will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers. Example Question: How frequently are you coughing? • Finding: Reports coughs last a few seconds (Available) Pro Tip: Establishing how long Danny's coughs last will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers. Example Question: How long do your coughs last? • Finding: Asked about aggravating factors for cough • Finding: Reports cough is worse at night (Found) Pro Tip: Establishing a timeline for Danny's coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers. Example Question: Is the cough worse at night? • Finding: Denies smoking (Available)

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Uploaded on
January 29, 2023
Number of pages
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Written in
2022/2023
Type
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