Daniel Rivera _ Focused Exam: Cough Results_Turned In | NR 509 Focused_Exam_Cough_Transcript

Focused Exam: Cough Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results L La ab b P Pa as ss s Started: Jun 04, 2018 | Patient Exam Time: 86 min Transcript Greet 06/04/18 2:50 PM CDT Question 06/04/18 2:51 PM CDT Question 06/04/18 2:52 PM CDT Question 06/04/18 2:52 PM CDT Question 06/04/18 2:52 PM CDT Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Self-Reflection I In nt te er rv viie ew w Q Qu ue es st tiio on ns s ( (7 76 6) ) S St ta at te em me en nt ts s ( (8 8) ) E Ex xa am m A Ac ct tiio on ns s ( (9 96 6) ) Hello, My name is Sara an FNP student and I will be interviewing you today Hi. What brought you into the clinic today? 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? My name is Daniel Rivera, but I just go by Danny. And how old are you? I'm eight. What is your date of birth? I was born March 4th in, um . . . [Danny reports correct birth year.] [AUDIO COMING SOON] A Allll L Liin ne es s ( (1 18 80 0) )6/4/2018 Focused Exam: Cough | Completed | Shadow Health 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 I'm sorry you feel so bad Thank you. When did your cough start? I think the cough started four. . . No, it started five days ago. Can you describe your place to me? My cough seems kind of gurgly and watery. Do you have any sputum? 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. How often are you coughing? I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night. How long does a cough last? I think the cough started four. . . No, it started five days ago. What is the duration of your cough? (Clarified to How would you describe your cough?.) My cough seems kind of gurgly and watery. What makes your cough worse?6/4/2018 Focused Exam: Cough | Completed | Shadow Health 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 My cough mostly stays the same no matter what I do. It seems to get worse at night though. Do you smoke? 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 know what triggers your cough? (No matching questions found.) What makes your cough worse? My cough mostly stays the same no matter what I do. It seems to get worse at night though. Are you exposed to anyone smoking? Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it's not all the time or anything. I don't like how it smells. Does your father smoke? Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it's not all the time or anything. I don't like how it smells. What makes your cough better? I had some cough medicine this morning. [AUDIO COMING SOON] Being exposed to secondhand smoke is almost just as bad as smoking, make sure you're around no one that is smoking Oh, OK.6/4/2018 Focused Exam: Cough | Completed | Shadow Health 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 What type of cough medicine do you take? (Clarified to Can you describe the cough medicine to me.) Um, it was purple-ish. It tasted gross. Do you know how much cough medicine you take? I just had one spoonful of it. Who gives you the medication? My mom. Any other things you were doing for your cough? My nose is a runny and I just feel kind of tired. Oh . . . my throat hurts a little bit too. But just a little bit. Are you using any home remedies for your cough? I had some cough medicine this morning. [AUDIO COMING SOON] Home remedies for cough? I had some cough medicine this morning. [AUDIO COMING SOON] Are you taking anything else for your cough? (Clarified to are you taking other medications.) I'm not taking any medicines every day. My mom gave me some cough medicine this morning though. Do you typically take medication every day? (Clarified to do you take any medications daily.)6/4/2018 Focused Exam: Cough | Completed | Shadow Health 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 I don't take any medicines every day. Do you take a vitamin? 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! You really should only take one as prescribed on the bottle of gummy dinosaurs Oh, OK. How is your activity level? I have gym class every day. I do all my exercises there. Abuela always has to remind me to play outside for a little bit on the weekends. . . I guess I like to play inside more. How are your classes in school I like school, but I guess sometimes it makes me feel bored if the homework is too easy. Is it hard for you to focus? (No matching questions found.) Is it hard for you to focus in school? (No matching questions found.) how is your school focus? I like school, but I guess sometimes it makes me feel bored if the homework is too easy. With your cough are you still able to play? (No matching questions found.)6/4/2018 Focused Exam: Cough | Completed | Shadow Health 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 Is your cough interfering with your play I don't usually wake up once I go to bed, but my cough has made it hard to fall asleep. Does your cough make it difficult to run? I don't usually wake up once I go to bed, but my cough has made it hard to fall asleep. How is your activity level? I have gym class every day. I do all my exercises there. Abuela always has to remind me to play outside for a little bit on the weekends. . . I guess I like to play inside more. It is always good to have physical exercise Oh, OK. Do you have a runny nose? My nose is always a little bit runny... but ever since I started coughing it's been worse, I think. Sneezing? I don't usually have to sneeze. My nose gets runny a lot of times though, like I have a cold. How often do you have a runny nose? Yeah, um, my nose is runny right now... it always seems a little bit runny. What color is your nasal discharge?6/4/2018 Focused Exam: Cough | Completed | Shadow Health 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 You mean like when I blow my nose? It's clear. Is the drainage from your nose thin? My nose is always a little bit runny... but ever since I started coughing it's been worse, I think. What is the consistency of your nasal drainage? It's kind of clear and, like, watery. Are you having any pain? Nothing really hurts. I've just had this cough for about five days. . . and I feel kind of tired. On a Pain Scale of 0 to 10 what would you rate your pain? Well, I have a little pain . . . in my right ear. Maybe almost a 3. Yeah. It's not too bad. I'm sorry you're in pain Thank you. Are you having pain in your ears? My right ear is starting to hurt a little bit . . . my left one is OK though. history of ear infections? (Clarified to have you ever had ear infections.)6/4/2018 Focused Exam: Cough | Completed | Shadow Health 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 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 any ear drainage? No, nothing comes out of my ears, but my right ear kind of hurts. I'm sorry to hear that- - - - - - - Continued