NURS 6512 Week 5 Focused Exam Cough Danny Rivera

Finding:

Established chief complaint

Finding:

Reports cough

(Found)

Example Question:

Finding:

Asked about onset of cough

Finding:

Reports cough started 5 days ago

(Found)

Example Question:

Finding:

Asked about frequency and duration of cough

Finding:

Reports coughing every few minutes

(Found)

Example Question:

Finding:

Asked about character of cough

Finding:

Reports cough is wet

(Found)

Example Question:

Finding:

Reports clear sputum

(Found)

Example Question:

Finding:

Asked about aggravating factors for cough

Finding:

Reports cough is worse at night

(Found)

Example Question:

Finding:

Reports exposure to secondhand smoke

(Found)

Example Question:

Finding: 

Denies knowing what makes the cough worse

(Found)

Example Question:

Finding:

Asked about relieving factors for cough

Finding:

Denies resting relieves cough

(Found)

Example Question:

Finding: 

Denies drinking water relieves cough

(Found)

Example Question:

Finding:

Asked about nasal symptoms

Finding: 

Reports current runny nose

(Found)

Example Question:

Finding:

Denies sneezing

(Found)

Example Question:

Finding: 

Reports frequent runny nose

(Found)

Example Question:

Finding:

Followed up on nasal discharge

Finding: 

Reports nasal discharge is clear

(Found)

Example Question:

Finding:

Reports nasal discharge is thin

(Found)

Example Question:

Finding: 

Asked about ear symptoms

Finding:

Reports pain in right ear

(Found)

Example Question:

Finding: 

Followed up on ear pain

Finding:

Reports ear pain started yesterday

(Found)

Example Question:

Finding: 

Reports ear pain is a 3 out of 10

(Found)

Example Question:

Finding: 

Denies ear discharge

(Found)

Example Question:

Finding:

Asked about throat symptoms

Finding: 

Reports sore throat

(Found)

Example Question: 

Finding:

Reports “a little” pain with swallowing

(Found) 

Example Question:

Finding: 

Asked about allergies

Finding:

Denies seasonal allergies

(Available) 

Example Question:

Finding: 

Denies food allergies

(Found)

Example Question:

Finding: 

Denies medication allergies

(Available)

Example Question:

Finding:

Denies allergies to animals

(Found) 

Example Question:

Finding:

Denies latex allergy

(Available)

Example Question:

Finding:

Asked about contact with illnesses

Finding: 

Denies being around anyone ill at home

(Found)

Example Question:

Finding:

Asked about home medications

Finding: 

Confirmed home medications

(Found)

Example Question:

Finding: 

Reports taking a daily vitamin

(Found)

Example Question:

Finding:

Reports taking cough medicine

(Found)

Example Question:

Finding: 

Followed up on cough medicine

Finding:

Reports cough medicine was purple

(Found)

Example Question:

Finding: 

Reports taking one spoonful of cough medicine

(Found)

Example Question:

Finding: 

Reports mother gave him the medicine

(Found)

Example Question:

Finding:

Reports cough medicine provided temporary relief

(Found) 

Example Question:

Finding:

Asked about relevant medical history

Finding:

Denies asthma diagnosis

(Found)

Example Question:

Finding: 

Reports immunizations as current

(Found)

Example Question:

Finding: 

Reports past pneumonia and frequent coughs

(Found)

Example Question:

Finding: 

Denies past hospitalizations

(Found)

Example Question:

Finding:

Asked about exposure to secondhand smoke

Finding:

Reports father smokes cigars

(Found)

Example Question:

Finding:

Reports father sometimes forgets to take cigars outside

(Found)

Example Question:

Finding:

Asked about living conditions

Finding:

Reports living in a house with parents and grandparents

(Available)

Example Question:

Finding:

Reports feeling safe at home

(Available) 

Example Question:

Finding:

Reports park with playground near home

(Found) 

Example Question:

Finding

Asked about constitutional health

Finding:

Denies fever

(Found)

Example Question:

Finding:

Denies chills

(Found)

Example Question:

Finding:

Reports feeling “kind of tired”

(Found)

Example Question:

Finding:

Denies night sweats

(Found)

Example Question:

Finding:

Denies weight loss

(Found)

Example Question:

Finding:

Denies appetite loss

(Found)

Example Question:

Finding:

Asked about review of systems for HEENT

Finding:

Denies ear popping or crackling

(Found)

Example Question:

Finding:

Reports history of frequent ear infections

(Found)

Example Question:

Finding:

Denies ear surgery or ear tubes

(Found)

Example Question:

Finding: 

Denies headaches

(Found)

Example Question:

Finding:

Denies nosebleeds

(Found)

Example Question:

Finding: 

Denies vision problems

(Available)

Example Question:

Finding: 

Denies dizziness

(Found)

Example Question:

Finding:

Denies watery eyes

(Found)

Example Question:

Finding:

Denies eye redness

(Found)

Example Question:

Finding:

Denies eye pain

(Found)

Example Question:

Finding:

Denies sinus pain

(Found)

Example Question:

Finding:

Denies hearing problems

(Found)

Example Question:

Finding: 

Asked about review of systems for respiratory

Finding:

Denies difficulty breathing

(Found)

Example Question:

Finding:

Denies chest tightness

(Found)

Example Question:

Fining: 

Denies chest pain

(Found)

Example Question:

Finding: 

Denies history of inhaler use or breathing treatments

Objective Data Collection: 11.27 of 13 (86.69%) – NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera

•  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)

•  7:00
•  Cone of light distorted

Left: Discharge (1/10 point)

•  No discharge
•  Cerumen
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

 Inspected mouth and throat

0.8 of 1 point

Oral Mucosa (No point)

•  Moist and pink
•  Dry appearance
•  Erythema

Tonsils (1/5 point) 

•  No visible abnormal find ings
•  Edema
•  Erythema

Posterior Oropharynx Color (1/5 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

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

0 of 1 point

Bronchophony (No point)

•  Positive
•  Negative

 Auscultated heart sounds

1 of 1 point NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

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 : 3 of 5 (60.0%)

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.
	How are you doing today ?	Question 12:38 PM MDT
	I don’t feel so good. I keep coughing and I feel a little bit tired.
	Oh, I’m sorry to hear that Danny	Empathize 12:39 PM MDT
	Thank you.
	How was your pain in your throat feels like ?	Question 01:44 PM MDT
	Um, it just feels kind of sore. I can feel it a little bit when I swallow.
	Oh, I am sorry to hear that Danny.	Empathize 01:46 PM MDT
	Thank you.
	Do you have a pain now ? (Clarified to: Do you have pain right now?)	Question 05:27 PM MDT
	The only thing that really hurts is my right ear, but it just hurts a little bit. It just started . . . I’m not sure what will make it feel better. (Clarified to: if I am in pain right now)
	I’m sorry to hear that	Empathize 05:27 PM MDT
	Thank you.
	How often do you said you are coughing ?	Question 05:27 PM MDT
	I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
	I’m sorry it must be really uncomfortable.	Empathize 05:28 PM MDT
	Thank you.
	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

Not Followed Up

 

	Description: Danny describes the medication he was given for his cough.
	What helps you cough ?	Question 01:01 PM MDT
	I had some cough medicine this morning. [AUDIO COMING SOON]
	Resting helps you ? (Clarified to: Does rest relieve your cough?)	Question 01:03 PM MDT
	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)
	Does drinking water helps your cough ?	Question 01:03 PM MDT
	Drinking water doesn’t do anything to my cough.
	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

Followed Up

 

	Description: Danny describes taking vitamins.
	You take vitamins ? (Clarified to: Do you take a multivitamin every day?)	Question 01:12 PM MDT
	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! (Clarified to: if I take a vitamin every day)
	It’s not good to take the extra one because it is important medication or vitamins dosages and the excess amount may hurt you.	Educate 01:14 PM MDT
	Oh, OK.
	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

Followed Up

 

	Description: Danny describes exposure to secondhand smoke at home.
	Do you smoke ?	Question 12:52 PM MDT
	No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell.
	Is Papi smokes at home around you ?	Question 12:54 PM MDT
	Yeah, sometimes Papi smokes cigars inside. He forgets to take them outside and my mom has to remind him. [AUDIO COMING SOON]
	It’s called secondary smoke When someone at home smokes they need to go to outside. Please dont be around the people who smoking. It is called secondary smoke. If you see somebody smoking and have no intentions to leave or you coming to the place where somebody smoked please do not stay in the same area. You need to leave. It is called secondary smoking and may affect your lungs when you inhale the smoke.	Educate 01:00 PM MDT
	Oh, OK.
	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.
	Is anybody sick in your house ?	Question 01:28 PM MDT
	Nobody at home is sick I don’t think.
	Do you have any family history of asthma ?	Question 01:28 PM MDT
	Mom says Papi had asthma when he was a little kid.
	Anybody in your family has allergies ?	Question 01:28 PM MDT
	I don’t think so, but I guess I’m not sure.
	Do you have any pets at home ?	Question 01:29 PM MDT
	No, but I keep asking my mom if I can get a lizard.
	What do you do when you have a free time ?	Question 01:30 PM MDT
	Usually I play video games or read or try to write stories. If Tony is here, we do that stuff together.
	Model Statement: “Thanks for telling me what you know about your family history. You did a good job remembering.”

Comments

Documentation / Electronic Health Record

• Document: Vitals
• Document: Provider Notes

Document: Vitals

Vitals
Blood Pressure	120/76
O2 Sat	96
Pulse	100
Resp. Rate	28
Temperature	37.2