NURS 6512 Week 5 Focused Exam Cough Danny Rivera

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NURS 6512 Week 5 Focused Exam Cough Danny Rivera

NURS 6512 Week 5 Focused Exam Cough Danny Rivera – ORDER THE INTERVIEW TRANSCRIPT AT A DISCOUNTED PRICE.

Experience Overview

Patient: Danny Rivera
NURS6512 Week 5 - Focused Exam: Cough Danny Rivera

Digital Clinical Experience Score

93.4%

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Student Performance Index

35.27

out of

39
 

Proficiency Level:

Proficient
Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.

Subjective Data Collection

21

out of

21

Objective Data Collection

11.27

out of

13

Education and Empathy

3

out of

5
 

Time

903 minutes total spent in assignment

Interaction with patient

903 minutes

Transcript – NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera

Started: Oct 03, 2020 | Total Time: 903 min

Subjective Data Collection: 21 of 21 (100.0%) – NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

  • Found:

     Indicates an item that you found.

  • Available:

     Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

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: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

Example Question:

Do you have a cough?
 

History of Present Illness

Finding:

Asked about onset of cough

Finding:

Reports cough started 5 days ago

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How long have you had a cough?

Finding:

Asked about frequency and duration of cough

Finding:

Reports coughing every few minutes

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How frequently have you been coughing?

Finding:

Asked about character of cough

Finding:

Reports cough is wet

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is your cough a wet cough?

Finding:

Reports clear sputum

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you produce any phlegm or sputum with your cough?

Finding:

Asked about aggravating factors for cough

Finding:

Reports cough is worse at night

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is your cough worse at night?

Finding:

Reports exposure to secondhand smoke

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Are you around anyone who smokes at home?

Finding: 

Denies knowing what makes the cough worse

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

What makes your cough worse?

Finding:

Asked about relieving factors for cough

Finding:

Denies resting relieves cough

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does resting help your cough?

Finding: 

Denies drinking water relieves cough

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does drinking water help your cough?

Finding:

Asked about nasal symptoms

Finding: 

Reports current runny nose

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have a runny nose?

Finding:

Denies sneezing

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Have you been sneezing?

Finding: 

Reports frequent runny nose

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you get runny noses often?

Finding:

Followed up on nasal discharge

Finding: 

Reports nasal discharge is clear

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

What color is your snot?

Finding:

Reports nasal discharge is thin

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Is your snot thin?

Finding: 

Asked about ear symptoms

Finding:

Reports pain in right ear

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have any ear pain?

Finding: 

Followed up on ear pain

Finding:

Reports ear pain started yesterday

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

How long have you had ear pain?

Finding: 

Reports ear pain is a 3 out of 10

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Can you rate your ear pain on a scale?

Finding: 

Denies ear discharge

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have any ear discharge?

Finding:

Asked about throat symptoms

Finding: 

Reports sore throat

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera

Example Question: 

Is your throat sore?

Finding:

Reports “a little” pain with swallowing

(Found) 

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Does it hurt when you swallow?

Finding: 

Asked about allergies

Finding:

Denies seasonal allergies

(Available) 

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have seasonal allergies?

Finding: 

Denies food allergies

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Do you have food allergies?

Finding: 

Denies medication allergies

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Are you allergic to any medicine?

Finding:

Denies allergies to animals

(Found) 

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Are you allergic to animals?

Finding:

Denies latex allergy

(Available)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

Example Question:

Are you allergic to latex?

Finding:

Asked about contact with illnesses

Finding: 

Denies being around anyone ill at home

(Found)

Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera

Example Question:

Is anyone sick at home?

Home Medications

Finding:

Asked about home medications

Finding: 

Confirmed home medications

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What medications do you take?

Finding: 

Reports taking a daily vitamin

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Do you take vitamins?

Finding:

Reports taking cough medicine

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Are you taking medication for your cough?

Finding: 

Followed up on cough medicine

Finding:

Reports cough medicine was purple

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

What color was the cough medicine?

Finding: 

Reports taking one spoonful of cough medicine

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

How much cough medicine did you take?

Finding: 

Reports mother gave him the medicine

(Found)

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Who gave you the cough medicine?

Finding:

Reports cough medicine provided temporary relief

(Found) 

Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

Example Question:

Did the cough medicine make you feel better?

Past Medical History

Finding:

Asked about relevant medical history

Finding:

Denies asthma diagnosis

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have asthma?

Finding: 

Reports immunizations as current

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have current immunizations?

Finding: 

Reports past pneumonia and frequent coughs

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Do you have a history of respiratory problems?

Finding: 

Denies past hospitalizations

(Found)

Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

Example Question:

Have you ever been to the hospital?

Social Determinants of Health

Finding:

Asked about exposure to secondhand smoke

Finding:

Reports father smokes cigars

(Found)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

Who smokes at home?

Finding:

Reports father sometimes forgets to take cigars outside

(Found)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

Where does your father smoke?

Social History

Finding:

Asked about living conditions

Finding:

Reports living in a house with parents and grandparents

(Available)

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Where do you live?

Finding:

Reports feeling safe at home

(Available) 

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera

Example Question:

Do you feel safe at home?

Finding:

Reports park with playground near home

(Found) 

Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

Example Question:

Is there anywhere near your home where you can play outside?

Review of Systems

Finding

Asked about constitutional health

Finding:

Denies fever

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have a fever?

Finding:

Denies chills

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have chills?

Finding:

Reports feeling “kind of tired”

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have fatigue?

Finding:

Denies night sweats

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have night sweats?

Finding:

Denies weight loss

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Has your weight changed?

Finding:

Denies appetite loss

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Have you lost your appetite?

Finding:

Asked about review of systems for HEENT

Finding:

Denies ear popping or crackling

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you hear any popping sounds?

Finding:

Reports history of frequent ear infections

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Have you ever had ear infections?

Finding:

Denies ear surgery or ear tubes

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Have you ever had surgery on your ears?

Finding: 

Denies headaches

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you get headaches?

Finding:

Denies nosebleeds

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have nosebleeds?

Finding: 

Denies vision problems

(Available)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any problems with your vision?

Finding: 

Denies dizziness

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera

Example Question:

Do you have any dizziness?

Finding:

Denies watery eyes

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have watery eyes?

Finding:

Denies eye redness

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have eye redness?

Finding:

Denies eye pain

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any eye pain?

Finding:

Denies sinus pain

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any sinus pain?

Finding:

Denies hearing problems

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any hearing problems?
 

Finding: 

Asked about review of systems for respiratory

Finding:

Denies difficulty breathing

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have difficulty breathing?

Finding:

Denies chest tightness

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have chest tightness?

Fining: 

Denies chest pain

(Found)

Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

Example Question:

Do you have any chest pain?

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.

  
This is your avatar.

How are you doing today ?

Question
12:38 PM MDT
Danny Rivera

I don’t feel so good. I keep coughing and I feel a little bit tired.

  
This is your avatar.

Oh, I’m sorry to hear that Danny

Empathize
12:39 PM MDT
Danny Rivera

Thank you.

  
This is your avatar.

How was your pain in your throat feels like ?

Question
01:44 PM MDT
Danny Rivera

Um, it just feels kind of sore. I can feel it a little bit when I swallow.

  
This is your avatar.

Oh, I am sorry to hear that Danny.

Empathize
01:46 PM MDT
Danny Rivera

Thank you.

  
This is your avatar.

Do you have a pain now ? (Clarified to: Do you have pain right now?)

Question
05:27 PM MDT
Danny Rivera

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)

  
This is your avatar.

I’m sorry to hear that

Empathize
05:27 PM MDT
Danny Rivera

Thank you.

  
This is your avatar.

How often do you said you are coughing ?

Question
05:27 PM MDT
Danny Rivera

I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.

  
This is your avatar.

I’m sorry it must be really uncomfortable.

Empathize
05:28 PM MDT
Danny Rivera

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.

  
This is your avatar.

What helps you cough ?

Question
01:01 PM MDT
Danny Rivera

I had some cough medicine this morning. [AUDIO COMING SOON]

  
This is your avatar.

Resting helps you ? (Clarified to: Does rest relieve your cough?)

Question
01:03 PM MDT
Danny Rivera

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)

  
This is your avatar.

Does drinking water helps your cough ?

Question
01:03 PM MDT
Danny Rivera

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.

  
This is your avatar.

You take vitamins ? (Clarified to: Do you take a multivitamin every day?)

Question
01:12 PM MDT
Danny Rivera

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)

  
This is your avatar.

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
Danny Rivera

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.

  
This is your avatar.

Do you smoke ?

Question
12:52 PM MDT
Danny Rivera

No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell.

  
This is your avatar.

Is Papi smokes at home around you ?

Question
12:54 PM MDT
Danny Rivera

Yeah, sometimes Papi smokes cigars inside. He forgets to take them outside and my mom has to remind him. [AUDIO COMING SOON]

  
This is your avatar.

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
Danny Rivera

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.

  
This is your avatar.

Is anybody sick in your house ?

Question
01:28 PM MDT
Danny Rivera

Nobody at home is sick I don’t think.

  
This is your avatar.

Do you have any family history of asthma ?

Question
01:28 PM MDT
Danny Rivera

Mom says Papi had asthma when he was a little kid.

  
This is your avatar.

Anybody in your family has allergies ?

Question
01:28 PM MDT
Danny Rivera

I don’t think so, but I guess I’m not sure.

  
This is your avatar.

Do you have any pets at home ?

Question
01:29 PM MDT
Danny Rivera

No, but I keep asking my mom if I can get a lizard.

  
This is your avatar.

What do you do when you have a free time ?

Question
01:30 PM MDT
Danny Rivera

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

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

Also Read: NURS6512 Week 7: Assessment of the Heart, Lungs, and Peripheral Vascular System