NURS6512 Week 5 Focused Exam Cough Danny Rivera

NURS6512 Week 5 Focused Exam Cough Danny Rivera

NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

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 – NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

Started: Oct 03, 2020 | Total Time: 903 min
Your avatar
Hi Danny my name is …., I am here to examine you today.

Greet
10/03/20 12:38 PM MDT

Danny Rivera
Hi.
Your avatar
How are you doing today ?

Question
10/03/20 12:38 PM MDT

Danny Rivera
I don’t feel so good. I keep coughing and I feel a little bit tired.
Your avatar
Oh, I’m sorry to hear that Danny

Empathize
10/03/20 12:39 PM MDT

Danny Rivera
Thank you.
Your avatar
How is the characteristics of your cough ?

Question
10/03/20 12:40 PM MDT

Danny Rivera
My cough seems kind of gurgly and watery.
Your avatar
Do you have a cough ?

Question
10/03/20 12:48 PM MDT

Danny Rivera
I guess I’m kind of sick. . . I’ve been coughing a lot.
Your avatar
How often do you have a cough ?

Question
10/03/20 12:48 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.
Your avatar
When it started ? (Clarified to When did the cough start?.)

Question
10/03/20 12:49 PM MDT

Danny Rivera
I think the cough started four. . . No, it started five days ago. (Clarified to when the cough started.)
Your avatar
How frequently have you been coughing ?

Question
10/03/20 12:50 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.
Your avatar
Is your cough wet cough ?

Question
10/03/20 12:50 PM MDT

Danny Rivera
Yeah . . . my cough seems kind of gurgly and watery.
Your avatar
Do you have a sputum ?

Question
10/03/20 12:51 PM MDT

Danny Rivera
Sometimes I cough up this slimy, clear stuff.
Your avatar
What aggravates your cough ?

Question
10/03/20 12:51 PM MDT

Danny Rivera
My cough mostly stays the same no matter what I do. It seems to get worse at night though.
Your avatar
Do you smoke ?

Question
10/03/20 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.
Your avatar
Lisa poppy smokes at home around you (No matching questions found.)

Question
10/03/20 12:52 PM MDT

Your avatar
Lisa poppy smokes at home around you ? (No matching questions found.)

Question
10/03/20 12:53 PM MDT

Your avatar
Lisa Papi smokes at home around you ? (No matching questions found.)

Question
10/03/20 12:53 PM MDT

Your avatar
Is Papi smokes at home around you ?

Question
10/03/20 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]
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.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

Educate
10/03/20 1:00 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Are there anything makes your cough worse ?

Question
10/03/20 1:00 PM MDT

Danny Rivera
My cough mostly stays the same no matter what I do. It seems to get worse at night though.
Your avatar
What helps you cough ?

Question
10/03/20 1:01 PM MDT

Danny Rivera
I had some cough medicine this morning. [AUDIO COMING SOON]
Your avatar
Resting helps you ? (Clarified to Does rest relieve your cough?.)

Question
10/03/20 1:03 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.)
Your avatar
Does drinking water helps your cough ?

Question
10/03/20 1:03 PM MDT

Danny Rivera
Drinking water doesn’t do anything to my cough.
Your avatar
Do you have any nasal problems ?

Question
10/03/20 1:04 PM MDT

Danny Rivera
My nose doesn’t get stuffed up. Oh, sometimes it gets runny though.
Your avatar
Do you sneeze ?

Question
10/03/20 1:04 PM MDT

Danny Rivera
I don’t usually have to sneeze. My nose gets runny a lot of times though, like I have a cold.
Your avatar
Do you have rhinorrhea ?

Question
10/03/20 1:05 PM MDT

Danny Rivera
I don’t have a rhino. My mom won’t even let me get a lizard. [AUDIO COMING SOON]NURS6512 Week 5 – Focused Exam: Cough Danny Rivera
Your avatar
Get runny nose often ?

Question
10/03/20 1:06 PM MDT

Danny Rivera
My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
Your avatar
Do you have a nasal discharge ?

Question
10/03/20 1:06 PM MDT

Danny Rivera
My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
Your avatar
Is there a discharge from your nose is clear ? (Clarified to Is the runny stuff from your nose clear?.)

Question
10/03/20 1:07 PM MDT

Danny Rivera
You mean like when I blow my nose? It’s clear. (Clarified to if my nasal discharge is clear.)
Your avatar
Is this stuff coming out from your nose is thin ? (Clarified to Is the runny stuff from your nose thick?.)

Question
10/03/20 1:08 PM MDT

Danny Rivera
It’s kind of clear and, like, watery. (Clarified to if I have thick nasal discharge.)
Your avatar
How about your ears ? (Clarified to How are your ears?.)

Question
10/03/20 1:09 PM MDT

Danny Rivera
My right ear is starting to hurt a little bit . . . my left one is OK though. (Clarified to how my ears are.)
Your avatar
Do you have any ear pain ?

Question
10/03/20 1:09 PM MDT

Danny Rivera
My right ear is starting to hurt a little bit . . . my left one is OK though.
Your avatar
How long have you had a ear pain ?

Question
10/03/20 1:10 PM MDT

Danny Rivera
My right ear just started hurting yesterday. I think it’s because I’m sick.
Your avatar
What is European from 1 to 10 ? (Clarified to How would you rate your ear pain on a 0-10 scale?.)

Question
10/03/20 1:10 PM MDT

Danny Rivera
Oh, I think it just hurts a little bit . . . three? (Clarified to how I would rate my ear pain on a scale.)
Your avatar
Do you have any discharge from your ears ?

Question
10/03/20 1:11 PM MDT

Danny Rivera
No, nothing comes out of my ears, but my right ear kind of hurts.
Your avatar
Do you have any problem in your throat ?

Question
10/03/20 1:11 PM MDT

Danny Rivera
My throat is sore, but just a little bit.
Your avatar
Do you have a pain when you swallow ?

Question
10/03/20 1:11 PM MDT

Danny Rivera
No, I can swallow OK. It hurts a little right now because my throat is kinda sore.
Your avatar
What type of medication do you take ?

Question
10/03/20 1:12 PM MDT

Danny Rivera
I took some cough medicine this morning. [AUDIO COMING SOON]
Your avatar
What does the name of cough medication ? (Clarified to Do you know what the cough medication’s name is?.)

Question
10/03/20 1:12 PM MDT

Danny Rivera
I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON] (Clarified to if I know what the cough medicine is called.)
Your avatar
You take vitamins ? (Clarified to Do you take a multivitamin every day?.)

Question
10/03/20 1:12 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.)NURS6512 Week 5 – Focused Exam: Cough Danny Rivera
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
10/03/20 1:14 PM MDT

Danny Rivera
Oh, OK.
Your avatar
How you taking medication for your cough ? (Clarified to Have you taken medicine for your cough?.)

Question
10/03/20 1:14 PM MDT

Danny Rivera
I had some cough medicine this morning. [AUDIO COMING SOON] (Clarified to if I have taken medicine for my cough.)
Your avatar
What does the color of your cough medication ? (Clarified to Can you describe the cough medicine to me?.)

Question
10/03/20 1:15 PM MDT

Danny Rivera
Um, it was purple-ish. It tasted gross. (Clarified to to describe the cough medicine.)
Your avatar
What is the amount of this medication you’re taking?

Question
10/03/20 1:15 PM MDT

Danny Rivera
I took some cough medicine this morning. [AUDIO COMING SOON]
Your avatar
How much of cough medication you took ? (Clarified to How much did you take of the cough medication?.)

Question
10/03/20 1:16 PM MDT

Danny Rivera
I just had one spoonful of it. (Clarified to how much cough medicine I took.)
Your avatar
Who give use a cough medicine ?

Question
10/03/20 1:16 PM MDT

Danny Rivera
My mom.
Your avatar
It’s a cough medication makes you feel better ?

Question
10/03/20 1:16 PM MDT

Danny Rivera
It helped a bit when my mom gave it to me, but my cough came back anyway.
Your avatar
Do you have any allergies ?

Question
10/03/20 1:17 PM MDT

Danny Rivera
I don’t really have any allergies. Tony has some though. He’s allergic to bees.
Your avatar
Do you have any food allergies ?

Question
10/03/20 1:17 PM MDT

Danny Rivera
I’m not allergic to any foods I don’t think.
Your avatar
Are you allergic to any animals ?

Question
10/03/20 1:17 PM MDT

Danny Rivera
I’m not allergic to any animals, which is good because I like them.
Your avatar
Do you have any let latex allergy ?

Question
10/03/20 1:18 PM MDT

Danny Rivera
I don’t really have any allergies. Tony has some though. He’s allergic to bees.
Your avatar
Who is Tony ?

Question
10/03/20 1:18 PM MDT

Danny Rivera
Tony’s my best friend.
Your avatar
Do you have any past medical history ?

Question
10/03/20 1:18 PM MDT

Danny Rivera
Oh, well, I have been sick before and I’m sick now . . . I had pneumonia once. Last year. My mom was really scared. She says I used to get earaches a lot too.
Your avatar
Do you have any asthma ?

Question
10/03/20 1:19 PM MDT

Danny Rivera
Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don’t have to.
Your avatar
How was your immunizations ? (Clarified to What immunizations have you had?.)

Question
10/03/20 1:19 PM MDT

Danny Rivera
Like getting shots? It seems like I get shots whenever I go to the doctor. Mom says I need them for school, but I hate it. (Clarified to what vaccines I have had.)
Your avatar
Have you ever been in the hospital ?

Question
10/03/20 1:20 PM MDT

Danny Rivera
I have never been to the hospital. My mom likes to watch doctor shows on TV, so I kind of know what it’s like.
Your avatar
Who smokes at home ?

Question
10/03/20 1:20 PM MDT

Danny Rivera
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.
Your avatar
Where does your father smoke ?

Question
10/03/20 1:21 PM MDT

Danny Rivera
Sometimes Papi forgets to go outside with his cigars. He’s usually in the kitchen or the living room when that happens.
Your avatar
Do you have any unusual frequent colds ?

Question
10/03/20 1:21 PM MDT

Danny Rivera
I get colds a lot. My nose is always runny.
Your avatar
Do you have a fever ?

Question
10/03/20 1:21 PM MDT

Danny Rivera
My mom said I didn’t have a fever this morning before Abuela took me here.
Your avatar
Do you have a chills ?

Question
10/03/20 1:21 PM MDT

Danny Rivera
No, I haven’t felt that.
Your avatar
Do you have a weakness ?

Question
10/03/20 1:22 PM MDT

Danny Rivera
I haven’t felt weak. . . I’m just kind of tired because my cough keeps me up at night.
Your avatar
Do you have any night sweats ?

Question
10/03/20 1:22 PM MDT

Danny Rivera
I don’t sweat at night unless it gets really hot or something.
Your avatar
Have you lost weight ?

Question
10/03/20 1:22 PM MDT

Danny Rivera
I guess I gained some weight actually. Some kids at recess called me chubby . . . My mom says I’m just growing though.
Your avatar
How is your appetite ?

Question
10/03/20 1:23 PM MDT

Danny Rivera
I think my appetite is normal.
Your avatar
Do you have any ear crackling or popping ?

Question
10/03/20 1:23 PM MDT

Danny Rivera
No, I haven’t noticed any popping in my ears, but my right ear kind of hurts.
Your avatar
Do you have any popping sounds ?

Question
10/03/20 1:23 PM MDT

Danny Rivera
No, I haven’t noticed any popping in my ears, but my right ear kind of hurts.
Your avatar
Have you ever had any ear infections ?

Question
10/03/20 1:24 PM MDT

Danny Rivera
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 . . .
Your avatar
Have you ever had any surgery on your ears?

Question
10/03/20 1:24 PM MDT

Danny Rivera
Mom says I used to get ear infections a lot when I was little, but I’m pretty sure I never had surgery for it.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera
Your avatar
Do you get headaches ?

Question
10/03/20 1:24 PM MDT

Danny Rivera
I don’t usually get headaches.
Your avatar
Do you have nose bleeds ?

Question
10/03/20 1:24 PM MDT

Danny Rivera
Just one time. Tony and I were kicking a ball at recess and I got hit in the nose.
Your avatar
Do you get dizzy ?

Question
10/03/20 1:25 PM MDT

Danny Rivera
I only get dizzy if I’m spinning around a lot at recess.
Your avatar
Your eyes getting watery ?

Question
10/03/20 1:25 PM MDT

Danny Rivera
No, my eyes don’t tear up. Well, I guess if I get sad or Papi is chopping onions for dinner they might.
Your avatar
Is your eyes getting red?

Question
10/03/20 1:25 PM MDT

Danny Rivera
I don’t think my eyes are ever red.
Your avatar
Do you have eye pain?

Question
10/03/20 1:25 PM MDT

Danny Rivera
No, my eyes don’t hurt, but they kind of feel like they do when I’m tired.
Your avatar
Do you have any sinus pain?

Question
10/03/20 1:26 PM MDT

Danny Rivera
It doesn’t hurt there.
Your avatar
Do you have hearing problems ?

Question
10/03/20 1:26 PM MDT

Danny Rivera
A lady came to my school to give all the kids a hearing test. It was kind of cool! I was hoping I would have super hearing, but I think I was just normal . . .
Your avatar
How was your breathing ?

Question
10/03/20 1:26 PM MDT

Danny Rivera
My breathing seems good. My nose is kind of runny right now, but I can still breathe OK.
Your avatar
Do you have any chest tightness?

Question
10/03/20 1:26 PM MDT

Danny Rivera
My chest feels okay.
Your avatar
Do you have any chest pain ?

Question
10/03/20 1:27 PM MDT

Danny Rivera
No, I don’t have pain in my chest. I would hate that!
Your avatar
Have you ever had any medications at in you inhaled ? (Clarified to Have you used an inhaler?.)

Question
10/03/20 1:27 PM MDT

Danny Rivera
No, I don’t use one of those. My friend Tony does though! (Clarified to if I have used an inhaler.)
Your avatar
Is anybody sick in your house ?

Question
10/03/20 1:28 PM MDT

Danny Rivera
Nobody at home is sick I don’t think.
Your avatar
Do you have any family history of asthma ?

Question
10/03/20 1:28 PM MDT

Danny Rivera
Mom says Papi had asthma when he was a little kid.
Your avatar
Anybody in your family has allergies ?

Question
10/03/20 1:28 PM MDT

Danny Rivera
I don’t think so, but I guess I’m not sure.
Your avatar
Do you have any pets at home ?

Question
10/03/20 1:29 PM MDT

Danny Rivera
No, but I keep asking my mom if I can get a lizard.
Your avatar
Where do you go when you have a free time ? (No matching questions found.)

Question
10/03/20 1:30 PM MDT

Your avatar
What do you do when you have a free time ?

Question
10/03/20 1:30 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.
Your avatar
How often you around smoking people ? (Clarified to How often are you around people who smoke?.)

Question
10/03/20 1:31 PM MDT

Danny Rivera
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. (Clarified to how often I am around secondhand smoke.)
Your avatar
Do you wash your hands ?

Question
10/03/20 1:38 PM MDT

Danny Rivera
I wash my hands before I eat or after I go to the bathroom.
Your avatar
How often do you wash your hands?

Question
10/03/20 1:39 PM MDT

Danny Rivera
I wash my hands before I eat or after I go to the bathroom.
Your avatar
Do you touch your nose often ?

Question
10/03/20 1:39 PM MDT

Danny Rivera
My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
Your avatar
You need to wash your hands more often.When you come from somewhere.

Educate
10/03/20 1:40 PM MDT

Danny Rivera
Oh, OK.
Your avatar
You need to wash your hands after you touch your nose. You may transfer a lot of infections or bacteria from your nose to door handles for example. If you dont wash your hands more often you can contaminate yourself or others with bacteria and possible viruses fro unwashed hands.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

Educate
10/03/20 1:44 PM MDT

Danny Rivera
Oh, OK.
Your avatar
 Checked vitals

Exam Action
10/03/20 1:44 PM MDT

Your avatar
 Tested lung capacity with spirometer: FEV1: 1.78L, FVC 1.549L (FEV1/FVC: 87%)

Exam Action
10/03/20 1:46 PM MDT

Your avatar
 Inspected mouth

Exam Action
10/03/20 1:48 PM MDT

Your avatar
 Inspected front of neck

Exam Action
10/03/20 1:48 PM MDT

Your avatar
 Inspected anterior chest wall

Exam Action
10/03/20 1:48 PM MDT

Your avatar
 Palpated maxillary sinuses: No tenderness reported

Exam Action
10/03/20 1:49 PM MDT

Your avatar
 Palpated frontal sinuses: No tenderness reported

Exam Action
10/03/20 1:49 PM MDT

Your avatar
 Palpated maxillary sinuses: No tenderness reported

Exam Action
10/03/20 1:49 PM MDT

Your avatar
 Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side

Exam Action
10/03/20 1:50 PM MDT

Your avatar
 Palpated axillary lymph nodes: Not palpable

Exam Action
10/03/20 1:50 PM MDT

Your avatar
 Palpated axillary lymph nodes: Not palpable

Exam Action
10/03/20 1:50 PM MDT

Your avatar
 Palpated supraclavicular lymph nodes: Not palpable

Exam Action
10/03/20 1:50 PM MDT

Your avatar
 Palpated axillary lymph nodes: Not palpable

Exam Action
10/03/20 1:50 PM MDT

Your avatar
 Palpated supraclavicular lymph nodes: Not palpable

Exam Action
10/03/20 1:51 PM MDT

Your avatar
 Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally

Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
 Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally

Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
 Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally

Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
 Palpated fremitus in posterior upper chest wall: Expected fremitus, equal bilaterally

Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
 Palpated fremitus in posterior middle chest wall: Expected fremitus, equal bilaterally

Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
 Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally

Exam Action
10/03/20 1:51 PM MDT

Your avatar
 Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally

Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
 Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally

Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
 Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally

Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
 Auscultated breath sounds in anterior right upper lobe

Exam Action
10/03/20 1:52 PM MDT

Your avatar
 Auscultated breath sounds in anterior left upper lobe

Exam Action
10/03/20 1:52 PM MDT

Your avatar
 Auscultated breath sounds in anterior left mid-chest (upper lobe)

Exam Action
10/03/20 1:52 PM MDT

Your avatar
 Auscultated breath sounds in anterior right middle lobe

Exam Action
10/03/20 1:52 PM MDT

Your avatar
 Auscultated breath sounds in anterior left mid-chest (upper lobe)

Exam Action
10/03/20 1:52 PM MDT

Your avatar
 Auscultated breath sounds in anterior right middle lobe

Exam Action
10/03/20 1:52 PM MDT

Your avatar
 Auscultated breath sounds in anterior right lower lobe

Exam Action
10/03/20 1:53 PM MDT

Your avatar
 Auscultated breath sounds in anterior left lower lobe

Exam Action
10/03/20 1:53 PM MDT

Your avatar
 Auscultated breath sounds in posterior right upper lobe

Exam Action
10/03/20 1:53 PM MDT

Your avatar
 Auscultated breath sounds in posterior left upper lobe

Exam Action
10/03/20 1:53 PM MDT

Your avatar
 Auscultated breath sounds in posterior left mid-back (lower lobe)

Exam Action
10/03/20 1:53 PM MDT

Your avatar
 Auscultated breath sounds in posterior right mid-back (lower lobe)

Exam Action
10/03/20 1:53 PM MDT

Your avatar
 Auscultated breath sounds in posterior left lower lobe near spine

Exam Action
10/03/20 1:53 PM MDT

Your avatar
 Auscultated breath sounds in posterior right lower lobe near spine

Exam Action
10/03/20 1:53 PM MDT

Your avatar
 Auscultated breath sounds in posterior right lower lobe

Exam Action
10/03/20 1:54 PM MDT

Your avatar
 Auscultated breath sounds in posterior left lower lobe

Exam Action
10/03/20 1:54 PM MDT

Your avatar
 Auscultated breath sounds in posterior left lower lobe on side

Exam Action
10/03/20 1:54 PM MDT

Your avatar
 Auscultated breath sounds in posterior right lower lobe on side

Exam Action
10/03/20 1:54 PM MDT

Your avatar
 Auscultated breath sounds in anterior left upper lobe

Exam Action
10/03/20 1:54 PM MDT

Your avatar
 Auscultated breath sounds in anterior right upper lobe

Exam Action
10/03/20 1:54 PM MDT

Your avatar
 Auscultated breath sounds in anterior right middle lobe

Exam Action
10/03/20 1:54 PM MDT

Your avatar
 Auscultated breath sounds in anterior left mid-chest (upper lobe)

Exam Action
10/03/20 1:54 PM MDT

Your avatar
 Auscultated breath sounds in anterior right middle lobe

Exam Action
10/03/20 1:54 PM MDT

Your avatar
 Auscultated breath sounds in anterior right lower lobe

Exam Action
10/03/20 1:54 PM MDT

Your avatar
 Percussed anterior right upper lobe

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed anterior left upper lobe

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed anterior right middle lobe

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed anterior left mid-chest (upper lobe)

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed anterior left lower lobe

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed anterior right lower lobe

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed posterior right upper lobe

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed posterior left upper lobe

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed posterior left mid-back (lower lobe)

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed posterior right mid-back (lower lobe)

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed posterior right lower lobe

Exam Action
10/03/20 1:55 PM MDT

Your avatar
 Percussed posterior right lower lobe near spine

Exam Action
10/03/20 1:56 PM MDT

Your avatar
 Percussed posterior left right lobe on side

Exam Action
10/03/20 1:56 PM MDT

Your avatar
 Percussed posterior left lower lobe near spine

Exam Action
10/03/20 1:56 PM MDT

Your avatar
 Percussed posterior left lower lobe

Exam Action
10/03/20 1:56 PM MDT

Your avatar
 Percussed posterior left lower lobe on side

Exam Action
10/03/20 1:56 PM MDT

Your avatar
 Percussed posterior left lower lobe on side

Exam Action
10/03/20 1:56 PM MDT

Your avatar
 Percussed posterior left lower lobe on side

Exam Action
10/03/20 1:56 PM MDT

Your avatar
 Checked vitals

Exam Action
10/03/20 1:56 PM MDT

Your avatar
Do you have sick friends ?

Question
10/03/20 5:03 PM MDT

Danny Rivera
None of my friends are sick that I know of.
Your avatar
Do you have anybody passing it around you ? (No matching questions found.)

Question
10/03/20 5:04 PM MDT

Your avatar
Do you have your friend Tony coughing around you ? (Clarified to Is tony sick?.)

Question
10/03/20 5:04 PM MDT

Danny Rivera
None of my friends are sick that I know of. (Clarified to if Tony is sick.)
Your avatar
Are you touching your nose ? (No matching questions found.)

Question
10/03/20 5:05 PM MDT

Your avatar
How often do you touch your nose ? (Clarified to How often do you blow your nose?.)

Question
10/03/20 5:05 PM MDT

Danny Rivera
Probably a million-billion times a day. [AUDIO COMING SOON] (Clarified to how often I blow my nose.)
Your avatar
Danny, signs you have been sick for last few days it’s very important that you practice strict hand hygiene and respiratory hygiene because you can develop upper respiratory infection. It is extremely important to prevent it.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

Educate
10/03/20 5:10 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Is anybody in your class sick ?

Question
10/03/20 5:35 PM MDT

Danny Rivera
Nobody I know is sick, I don’t think.
Your avatar
How is the Tony feels ?

Question
10/03/20 5:36 PM MDT

Danny Rivera
None of my friends are sick that I know of.
Your avatar
What type of diet do you have ?

Question
10/03/20 5:39 PM MDT

Danny Rivera
Mom says I’m picky. I can clean my plate… if I like the food. Yeah. I eat breakfast and I eat all my dinner.
Your avatar
What do you like to eat for breakfast ?

Question
10/03/20 5:39 PM MDT

Danny Rivera
I have cereal with milk and fruit most mornings. Sometimes I have a waffle or eggs and bacon.
Your avatar
Do you do exercises ?

Question
10/03/20 5:39 PM MDT

Danny Rivera
I have gym class every day. I do all my exercises there. And there’s a park right next to my house where I play after school, or sometimes on the weekends, if it’s nice outside. [AUDIO COMING SOON]
Your avatar
Can you minimize the amount of waffle and bacon which is not good for your health. It is low in nutritions and high in fats and carbohydrates.

Educate
10/03/20 5:44 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Also I would like to recommend you to increase your fluid intake. It will help your body to be clean and to get rid of bacterias and infections.

Educate
10/03/20 5:47 PM MDT

Danny Rivera
Oh, OK.
Your avatar
 Inspected mouth

Exam Action
10/04/20 3:15 AM MDT

Your avatar
Can I take a look at your mouth again ?

Question
10/04/20 3:16 AM MDT

Danny Rivera
Sure.
Your avatar
 Performed otoscopic examination of right ear

Exam Action
10/04/20 3:17 AM MDT

Your avatar
Can I examine you more Danny ?

Question
10/04/20 3:18 AM MDT

Danny Rivera
Sure.
Your avatar
 Performed otoscopic examination of left ear

Exam Action
10/04/20 3:18 AM MDT

Your avatar
 Performed otoscopic examination of right ear

Exam Action
10/04/20 3:18 AM MDT

Your avatar
 Performed otoscopic examination of left ear

Exam Action
10/04/20 3:19 AM MDT

Your avatar
 Inspected mouth

Exam Action
10/04/20 3:29 AM MDT

Your avatar
Danny how often you washing your hands ?

Question
10/04/20 1:37 PM MDT

Danny Rivera
I wash my hands before I eat or after I go to the bathroom.
Your avatar
You need to wash your hands more often or to use hand sanitizer.

Educate
10/04/20 1:38 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Do you play with a sick peer ?

Question
10/04/20 1:38 PM MDT

Danny Rivera
I have a lot of girls that are friends, but no girlfriends really. Not yet! There are some girls I think are pretty though.
Your avatar
When your cough started ?

Question
10/04/20 1:39 PM MDT

Danny Rivera
I think the cough started four. . . No, it started five days ago.
Your avatar
Where do you have your pain ?

Question
10/04/20 1:40 PM MDT

Danny Rivera
My right ear kind of hurts . . . but it’s just my cough that has been keeping me up at night. Oh, well, my throat is a little bit sore.
Your avatar
Do you have any discharge from your right ear ?

Question
10/04/20 1:41 PM MDT

Danny Rivera
No, nothing comes out of my ears, but my right ear kind of hurts.
Your avatar
Do you have sore throat ?

Question
10/04/20 1:41 PM MDT

Danny Rivera
It feels a little bit sore, yeah.
Your avatar
How would you describe your pain ?

Question
10/04/20 1:41 PM MDT

Danny Rivera
Um. . . I don’t know. It just hurts. But it’s not so bad.
Your avatar
In a scale from 1 to 10 how would you describe your pain ? (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)

Question
10/04/20 1:41 PM MDT

Danny Rivera
Well, I have a little pain . . . in my right ear. Maybe almost a 3. Yeah. It’s not too bad. (Clarified to how I would rate my pain on a scale.)
Your avatar
Do you take something for pain ? (Clarified to Are you taking anything for pain?.)

Question
10/04/20 1:42 PM MDT

Danny Rivera
I don’t take medicine for pain. I only take the medicine my mom or Abuela give me. (Clarified to if I am taking pain medication.)
Your avatar
Who is Abuela ?

Question
10/04/20 1:42 PM MDT

Danny Rivera
Abuela is my grandma . . . she’s my mom’s mom!
Your avatar
Did you say your pain like watery and gurgle ? (No matching questions found.)NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

Question
10/04/20 1:43 PM MDT

Your avatar
Did you say your pain like watery and gurgle ? (No matching questions found.)

Question
10/04/20 1:43 PM MDT

Your avatar
Did you say that your pain pills like watery ? (No matching questions found.)

Question
10/04/20 1:44 PM MDT

Your avatar
How was your pain in your throat feels like ?

Question
10/04/20 1:44 PM MDT

Danny Rivera
Um, it just feels kind of sore. I can feel it a little bit when I swallow.
Your avatar
Oh, I am sorry to hear that Danny.

Empathize
10/04/20 1:46 PM MDT

Danny Rivera
Thank you.
Your avatar
Danny how much water do you take ?

Question
10/04/20 1:59 PM MDT

Danny Rivera
I drink water a lot. . . whenever I’m not drinking it enough, Abuela always makes me drink more.
Your avatar
How many cups of water do you drink per day ?

Question
10/04/20 2:00 PM MDT

Danny Rivera
I usually have 7 or 8 glasses of water a day.
Your avatar
Is Tony used uses an inhaler ? (Clarified to Is Tony your brother?.)

Question
10/04/20 2:07 PM MDT

Danny Rivera
Tony’s my best friend. (Clarified to if Tony is my brother.)
Your avatar
Do you know is Tony uses inhaler

Question
10/04/20 2:08 PM MDT

Danny Rivera
None of my friends are sick that I know of.
Your avatar
Danny you need to stay away from sick people ok ?

Educate
10/04/20 5:05 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Danny, if you see that people around you coughing and sneezing you dont need to keep close communications with them. Also I will let your parents to provide you with hand sanitizer, you need to use it after using bathroom, if you touched some doors or any other interactions and touching other things.

Educate
10/04/20 5:09 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Also drink plenty of fluids are very important for your body. It will help to loosen the mucus in your nose and help congestion when you have symptoms of infections like you do now.

Educate
10/04/20 5:13 PM MDT

Danny Rivera
Oh, OK.
Your avatar
When you cough, you need to cough into the tissue. If you dont have a tissue, use the sleeve to cover the mouth.

Educate
10/04/20 5:15 PM MDT

Danny Rivera
Oh, OK.
Your avatar
I am going to tell your father not to smoke in the house. You remind him too if he forgets or go to other room. I will follow up about it.

Educate
10/04/20 5:21 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Danny I would like to communicate with your parents about todays recommendations and schedule follow up appointment. Are you ok with that ? (No matching questions found.)

Question
10/04/20 5:24 PM MDT

Your avatar
Danny, I would like to communicate with your parents about todays recommendations and schedule follow up appointment.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

Educate
10/04/20 5:24 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Also, please do not touch your face, nose, mouth, eyes with your hands. You can transmit more infection to yourself and others which we need to prevent. (No matching questions found.)

Question
10/04/20 5:26 PM MDT

Your avatar
Also, please do not touch your face, nose, mouth, eyes with your hands. You can transmit more infection to yourself and others which we need to prevent.

Educate
10/04/20 5:26 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Do you have a pain now ? (Clarified to Do you have pain right now?.)

Question
10/04/20 5:27 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.)
Your avatar
I’m sorry to hear that

Empathize
10/04/20 5:27 PM MDT

Danny Rivera
Thank you.
Your avatar
How often do you said you are coughing ?

Question
10/04/20 5:27 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.
Your avatar
I’m sorry it must be really uncomfortable.

Empathize
10/04/20 5:28 PM MDT

Danny Rivera
Thank you.
Your avatar
What type of medication are you taking for your cough ?

Question
10/04/20 5:47 PM MDT

Danny Rivera
I took some cough medicine this morning. [AUDIO COMING SOON]
Your avatar
What type of medication is this ? (Clarified to What medications do you take?.)

Question
10/04/20 5:47 PM MDT

Danny Rivera
I took some cough medicine this morning. [AUDIO COMING SOON] (Clarified to what medications I am taking.)
Your avatar
Do you know what is the name of this medication ? (Clarified to What is the name of the cough medicine you took?.)

Question
10/04/20 5:48 PM MDT

Danny Rivera
I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON] (Clarified to what the name of the cough medicine is.)
Your avatar
do you know the name of the medication for the cough ?

Question
10/04/20 5:49 PM MDT

Danny Rivera
I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON]
Your avatar
ok, I can ask your mom about it. (No matching questions found.)

Question
10/04/20 5:49 PM MDT

Your avatar
How long does medication was relieving your symptoms ? (No matching questions found.)

Question
10/04/20 5:50 PM MDT

Your avatar
How long does cough medication was relieving your symptoms ?

Question
10/04/20 5:50 PM MDT

Danny Rivera
My mom gave me some medicine and it helped my cough a little bit, but it started again.
Your avatar
How long you tipped you feel better after taking this medication ? (Clarified to Did the medicine make your cough better?.)

Question
10/04/20 5:51 PM MDT

Danny Rivera
It helped a bit when my mom gave it to me, but my cough came back anyway. (Clarified to if the medicine helped my cough.)

Subjective Data Collection: 21 of 21 (100.0%) – NURS6512 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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

  • 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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Do you have a cough?

NURS6512 Week 5 Focused Exam Cough Danny Rivera 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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

NURS6512 Week 5 Focused Exam Cough Danny Rivera 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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Is your cough a wet cough?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Are you around anyone who smokes at home?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

What makes your cough worse?

Finding:

Asked about relieving factors for cough

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Does resting help your cough?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Does drinking water help your cough?

Finding:

Asked about nasal symptoms

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Have you been sneezing?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Do you get runny noses often?

Finding:

Followed up on nasal discharge

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Is your snot thin?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Do you have any ear pain?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

How long have you had ear pain?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Can you rate your ear pain on a scale?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Do you have any ear discharge?

Finding:

Asked about throat symptoms

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

Example Question: NURS6512 Week 5 Focused Exam Cough Danny Rivera

Is your throat sore?

Finding:

Reports “a little” pain with swallowing

(Found) NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

Asked about allergies

Finding:

Denies seasonal allergies

(Available) NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Do you have food allergies?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

Are you allergic to any medicine?

Finding:

Denies allergies to animals

(Found) NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

Are you allergic to latex?

Finding:

Asked about contact with illnesses

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

Example Question: NURS6512 Week 5 Focused Exam Cough Danny Rivera

Is anyone sick at home?

Home Medications

Finding:

Asked about home medications

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

What color was the cough medicine?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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) NURS6512 Week 5 Focused Exam Cough Danny Rivera

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 NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Do you have asthma?

Finding: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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 NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

Example Question:

Where does your father smoke?

Social History NURS6512 Week 5 Focused Exam Cough Danny Rivera

Finding:

Asked about living conditions

Finding:

Reports living in a house with parents and grandparents

(Available) NURS6512 Week 5 Focused Exam Cough Danny Rivera

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) NURS6512 Week 5 Focused Exam Cough Danny Rivera

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.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

Example Question:

Do you feel safe at home?

Finding:

Reports park with playground near home

(Found) NURS6512 Week 5 Focused Exam Cough Danny Rivera

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 NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

Example Question:

Do you have any dizziness?

Finding:NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

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: NURS6512 Week 5 Focused Exam Cough Danny Rivera

Denies history of inhaler use or breathing treatments

Objective Data Collection: 11.27 of 13 (86.69%) – NURS6512 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) NURS6512 Week 5 Focused Exam Cough Danny Rivera
  •  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
NURS6512 Week 5 Focused Exam Cough Danny Rivera 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

NURS6512 Week 5 Focused Exam Cough Danny Rivera 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.

NURS6512 Week 5 Focused Exam Cough Danny Rivera
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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

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 ? NURS6512 Week 5 Focused Exam Cough Danny Rivera

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.NURS6512 Week 5 Focused Exam Cough Danny Rivera

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 ? NURS6512 Week 5 Focused Exam Cough Danny Rivera

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.

NURS6512 Week 5 Focused Exam Cough Danny Rivera

 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)

NURS6512 Week 5 Focused Exam Cough Danny Rivera
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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

 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 ? NURS6512 Week 5 Focused Exam Cough Danny Rivera

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.

NURS6512 Week 5 Focused Exam Cough Danny Rivera

 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 ? NURS6512 Week 5 Focused Exam Cough Danny Rivera

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. NURS6512 Week 5 Focused Exam Cough Danny Rivera

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 NURS6512 Week 5 Focused Exam Cough Danny Rivera

Documentation / Electronic Health Record

Document: Vitals

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

NURS6512 Week 5 Focused Exam Cough Danny Rivera

mersin escmersin esc