NURS 6512 Week 5 Focused Exam Cough Danny Rivera

NURS 6512 Week 5 Focused Exam Cough Danny Rivera

Patient: Danny Rivera

Digital Clinical Experience Score

93.4%

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Student Performance Index

35.27

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Proficiency Level:

Proficient

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Subjective Data Collection

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Objective Data Collection

11.27

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903 minutes total spent in assignment

Interaction with patient

903 minutes

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

	Hi Danny my name is …., I am here to examine you today.	Greet 10/03/20 12:38 PM MDT
	Hi.
	How are you doing today ?	Question 10/03/20 12:38 PM MDT
	I don’t feel so good. I keep coughing and I feel a little bit tired.
	Oh, I’m sorry to hear that Danny	Empathize 10/03/20 12:39 PM MDT
	Thank you.
	How is the characteristics of your cough ?	Question 10/03/20 12:40 PM MDT
	My cough seems kind of gurgly and watery.
	Do you have a cough ?	Question 10/03/20 12:48 PM MDT
	I guess I’m kind of sick. . . I’ve been coughing a lot.
	How often do you have a cough ?	Question 10/03/20 12:48 PM MDT
	I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
	When it started ? (Clarified to When did the cough start?.)	Question 10/03/20 12:49 PM MDT
	I think the cough started four. . . No, it started five days ago. (Clarified to when the cough started.)
	How frequently have you been coughing ?	Question 10/03/20 12:50 PM MDT
	I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
	Is your cough wet cough ?	Question 10/03/20 12:50 PM MDT
	Yeah . . . my cough seems kind of gurgly and watery.
	Do you have a sputum ?	Question 10/03/20 12:51 PM MDT
	Sometimes I cough up this slimy, clear stuff.
	What aggravates your cough ?	Question 10/03/20 12:51 PM MDT
	My cough mostly stays the same no matter what I do. It seems to get worse at night though.
	Do you smoke ?	Question 10/03/20 12:52 PM MDT
	No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell.
	Lisa poppy smokes at home around you (No matching questions found.)	Question 10/03/20 12:52 PM MDT
	Lisa poppy smokes at home around you ? (No matching questions found.)	Question 10/03/20 12:53 PM MDT
	Lisa Papi smokes at home around you ? (No matching questions found.)	Question 10/03/20 12:53 PM MDT
	Is Papi smokes at home around you ?	Question 10/03/20 12:54 PM MDT
	Yeah, sometimes Papi smokes cigars inside. He forgets to take them outside and my mom has to remind him. [AUDIO COMING SOON]
	It’s called secondary smoke When someone at home smokes they need to go to outside. Please dont be around the people who smoking. It is called secondary smoke. If you see somebody smoking and have no intentions to leave or you coming to the place where somebody smoked please do not stay in the same area. You need to leave. It is called secondary smoking and may affect your lungs when you inhale the smoke.NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera	Educate 10/03/20 1:00 PM MDT
	Oh, OK.
	Are there anything makes your cough worse ?	Question 10/03/20 1:00 PM MDT
	My cough mostly stays the same no matter what I do. It seems to get worse at night though.
	What helps you cough ?	Question 10/03/20 1:01 PM MDT
	I had some cough medicine this morning. [AUDIO COMING SOON]
	Resting helps you ? (Clarified to Does rest relieve your cough?.)	Question 10/03/20 1:03 PM MDT
	My cough has just stayed the same. I’ve taken some naps, but it doesn’t seem to help. (Clarified to if rest relieves my cough.)
	Does drinking water helps your cough ?	Question 10/03/20 1:03 PM MDT
	Drinking water doesn’t do anything to my cough.
	Do you have any nasal problems ?	Question 10/03/20 1:04 PM MDT
	My nose doesn’t get stuffed up. Oh, sometimes it gets runny though.
	Do you sneeze ?	Question 10/03/20 1:04 PM MDT
	I don’t usually have to sneeze. My nose gets runny a lot of times though, like I have a cold.
	Do you have rhinorrhea ?	Question 10/03/20 1:05 PM MDT
	I don’t have a rhino. My mom won’t even let me get a lizard. [AUDIO COMING SOON] NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera
	Get runny nose often ?	Question 10/03/20 1:06 PM MDT
	My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
	Do you have a nasal discharge ?	Question 10/03/20 1:06 PM MDT
	My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
	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
	You mean like when I blow my nose? It’s clear. (Clarified to if my nasal discharge is clear.)
	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
	It’s kind of clear and, like, watery. (Clarified to if I have thick nasal discharge.)
	How about your ears ? (Clarified to How are your ears?.)	Question 10/03/20 1:09 PM MDT
	My right ear is starting to hurt a little bit . . . my left one is OK though. (Clarified to how my ears are.)
	Do you have any ear pain ?	Question 10/03/20 1:09 PM MDT
	My right ear is starting to hurt a little bit . . . my left one is OK though.
	How long have you had a ear pain ?	Question 10/03/20 1:10 PM MDT
	My right ear just started hurting yesterday. I think it’s because I’m sick.
	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
	Oh, I think it just hurts a little bit . . . three? (Clarified to how I would rate my ear pain on a scale.)
	Do you have any discharge from your ears ?	Question 10/03/20 1:11 PM MDT
	No, nothing comes out of my ears, but my right ear kind of hurts.
	Do you have any problem in your throat ?	Question 10/03/20 1:11 PM MDT
	My throat is sore, but just a little bit.
	Do you have a pain when you swallow ?	Question 10/03/20 1:11 PM MDT
	No, I can swallow OK. It hurts a little right now because my throat is kinda sore.
	What type of medication do you take ?	Question 10/03/20 1:12 PM MDT
	I took some cough medicine this morning. [AUDIO COMING SOON]
	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
	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.)
	You take vitamins ? (Clarified to Do you take a multivitamin every day?.)	Question 10/03/20 1:12 PM MDT
	Oh yeah, I take vitamins every day! The gummy dinosaur kind. I don’t think I’m supposed to, but sometimes I sneak extra ones to be super healthy! (Clarified to if I take a vitamin every day.)NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera
	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
	Oh, OK.
	How you taking medication for your cough ? (Clarified to Have you taken medicine for your cough?.)	Question 10/03/20 1:14 PM MDT
	I had some cough medicine this morning. [AUDIO COMING SOON] (Clarified to if I have taken medicine for my cough.)
	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
	Um, it was purple-ish. It tasted gross. (Clarified to to describe the cough medicine.)
	What is the amount of this medication you’re taking?	Question 10/03/20 1:15 PM MDT
	I took some cough medicine this morning. [AUDIO COMING SOON]
	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
	I just had one spoonful of it. (Clarified to how much cough medicine I took.)
	Who give use a cough medicine ?	Question 10/03/20 1:16 PM MDT
	My mom.
	It’s a cough medication makes you feel better ?	Question 10/03/20 1:16 PM MDT
	It helped a bit when my mom gave it to me, but my cough came back anyway.
	Do you have any allergies ?	Question 10/03/20 1:17 PM MDT
	I don’t really have any allergies. Tony has some though. He’s allergic to bees.
	Do you have any food allergies ?	Question 10/03/20 1:17 PM MDT
	I’m not allergic to any foods I don’t think.
	Are you allergic to any animals ?	Question 10/03/20 1:17 PM MDT
	I’m not allergic to any animals, which is good because I like them.
	Do you have any let latex allergy ?	Question 10/03/20 1:18 PM MDT
	I don’t really have any allergies. Tony has some though. He’s allergic to bees.
	Who is Tony ?	Question 10/03/20 1:18 PM MDT
	Tony’s my best friend.
	Do you have any past medical history ?	Question 10/03/20 1:18 PM MDT
	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.
	Do you have any asthma ?	Question 10/03/20 1:19 PM MDT
	Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don’t have to.
	How was your immunizations ? (Clarified to What immunizations have you had?.)	Question 10/03/20 1:19 PM MDT
	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.)
	Have you ever been in the hospital ?	Question 10/03/20 1:20 PM MDT
	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.
	Who smokes at home ?	Question 10/03/20 1:20 PM MDT
	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.
	Where does your father smoke ?	Question 10/03/20 1:21 PM MDT
	Sometimes Papi forgets to go outside with his cigars. He’s usually in the kitchen or the living room when that happens.
	Do you have any unusual frequent colds ?	Question 10/03/20 1:21 PM MDT
	I get colds a lot. My nose is always runny.
	Do you have a fever ?	Question 10/03/20 1:21 PM MDT
	My mom said I didn’t have a fever this morning before Abuela took me here.
	Do you have a chills ?	Question 10/03/20 1:21 PM MDT
	No, I haven’t felt that.
	Do you have a weakness ?	Question 10/03/20 1:22 PM MDT
	I haven’t felt weak. . . I’m just kind of tired because my cough keeps me up at night.
	Do you have any night sweats ?	Question 10/03/20 1:22 PM MDT
	I don’t sweat at night unless it gets really hot or something.
	Have you lost weight ?	Question 10/03/20 1:22 PM MDT
	I guess I gained some weight actually. Some kids at recess called me chubby . . . My mom says I’m just growing though.
	How is your appetite ?	Question 10/03/20 1:23 PM MDT
	I think my appetite is normal.
	Do you have any ear crackling or popping ?	Question 10/03/20 1:23 PM MDT
	No, I haven’t noticed any popping in my ears, but my right ear kind of hurts.
	Do you have any popping sounds ? ORDER A PLAGIARISM-FREE PAPER HERE	Question 10/03/20 1:23 PM MDT
	No, I haven’t noticed any popping in my ears, but my right ear kind of hurts.
	Have you ever had any ear infections ?	Question 10/03/20 1:24 PM MDT
	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 . . .
	Have you ever had any surgery on your ears?	Question 10/03/20 1:24 PM MDT
	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.NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera
	Do you get headaches ?	Question 10/03/20 1:24 PM MDT
	I don’t usually get headaches.
	Do you have nose bleeds ?	Question 10/03/20 1:24 PM MDT
	Just one time. Tony and I were kicking a ball at recess and I got hit in the nose.
	Do you get dizzy ?	Question 10/03/20 1:25 PM MDT
	I only get dizzy if I’m spinning around a lot at recess.
	Your eyes getting watery ?	Question 10/03/20 1:25 PM MDT
	No, my eyes don’t tear up. Well, I guess if I get sad or Papi is chopping onions for dinner they might.
	Is your eyes getting red?	Question 10/03/20 1:25 PM MDT
	I don’t think my eyes are ever red.
	Do you have eye pain?	Question 10/03/20 1:25 PM MDT
	No, my eyes don’t hurt, but they kind of feel like they do when I’m tired.
	Do you have any sinus pain?	Question 10/03/20 1:26 PM MDT
	It doesn’t hurt there.
	Do you have hearing problems ?	Question 10/03/20 1:26 PM MDT
	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 . . .
	How was your breathing ?	Question 10/03/20 1:26 PM MDT
	My breathing seems good. My nose is kind of runny right now, but I can still breathe OK.
	Do you have any chest tightness?	Question 10/03/20 1:26 PM MDT
	My chest feels okay.
	Do you have any chest pain ?	Question 10/03/20 1:27 PM MDT
	No, I don’t have pain in my chest. I would hate that!
	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
	No, I don’t use one of those. My friend Tony does though! (Clarified to if I have used an inhaler.)
	Is anybody sick in your house ?	Question 10/03/20 1:28 PM MDT
	Nobody at home is sick I don’t think.
	Do you have any family history of asthma ?	Question 10/03/20 1:28 PM MDT
	Mom says Papi had asthma when he was a little kid.
	Anybody in your family has allergies ?	Question 10/03/20 1:28 PM MDT
	I don’t think so, but I guess I’m not sure.
	Do you have any pets at home ?	Question 10/03/20 1:29 PM MDT
	No, but I keep asking my mom if I can get a lizard.
	Where do you go when you have a free time ? (No matching questions found.)	Question 10/03/20 1:30 PM MDT
	What do you do when you have a free time ?	Question 10/03/20 1:30 PM MDT
	Usually I play video games or read or try to write stories. If Tony is here, we do that stuff together.
	How often you around smoking people ? (Clarified to How often are you around people who smoke?.)	Question 10/03/20 1:31 PM MDT
	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.)
	Do you wash your hands ?	Question 10/03/20 1:38 PM MDT
	I wash my hands before I eat or after I go to the bathroom.
	How often do you wash your hands?	Question 10/03/20 1:39 PM MDT
	I wash my hands before I eat or after I go to the bathroom.
	Do you touch your nose often ?	Question 10/03/20 1:39 PM MDT
	My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
	You need to wash your hands more often.When you come from somewhere.	Educate 10/03/20 1:40 PM MDT
	Oh, OK.
	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
	Oh, OK.
	Checked vitals	Exam Action 10/03/20 1:44 PM MDT
	Tested lung capacity with spirometer: FEV1: 1.78L, FVC 1.549L (FEV1/FVC: 87%)	Exam Action 10/03/20 1:46 PM MDT
	Inspected mouth	Exam Action 10/03/20 1:48 PM MDT
	Inspected front of neck	Exam Action 10/03/20 1:48 PM MDT
	Inspected anterior chest wall	Exam Action 10/03/20 1:48 PM MDT
	Palpated maxillary sinuses: No tenderness reported	Exam Action 10/03/20 1:49 PM MDT
	Palpated frontal sinuses: No tenderness reported	Exam Action 10/03/20 1:49 PM MDT
	Palpated maxillary sinuses: No tenderness reported	Exam Action 10/03/20 1:49 PM MDT
	Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side	Exam Action 10/03/20 1:50 PM MDT
	Palpated axillary lymph nodes: Not palpable	Exam Action 10/03/20 1:50 PM MDT
	Palpated axillary lymph nodes: Not palpable	Exam Action 10/03/20 1:50 PM MDT
	Palpated supraclavicular lymph nodes: Not palpable	Exam Action 10/03/20 1:50 PM MDT
	Palpated axillary lymph nodes: Not palpable	Exam Action 10/03/20 1:50 PM MDT
	Palpated supraclavicular lymph nodes: Not palpable	Exam Action 10/03/20 1:51 PM MDT
	Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally	Exam Action 10/03/20 1:51 PM MDT
	Ninety-nine.
	Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally	Exam Action 10/03/20 1:51 PM MDT
	Ninety-nine.
	Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally	Exam Action 10/03/20 1:51 PM MDT
	Ninety-nine.
	Palpated fremitus in posterior upper chest wall: Expected fremitus, equal bilaterally	Exam Action 10/03/20 1:51 PM MDT
	Ninety-nine.
	Palpated fremitus in posterior middle chest wall: Expected fremitus, equal bilaterally	Exam Action 10/03/20 1:51 PM MDT
	Ninety-nine.
	Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally	Exam Action 10/03/20 1:51 PM MDT
	Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally	Exam Action 10/03/20 1:51 PM MDT
	Ninety-nine.
	Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally	Exam Action 10/03/20 1:51 PM MDT
	Ninety-nine.
	Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally	Exam Action 10/03/20 1:51 PM MDT
	Ninety-nine.
	Auscultated breath sounds in anterior right upper lobe	Exam Action 10/03/20 1:52 PM MDT
	Auscultated breath sounds in anterior left upper lobe	Exam Action 10/03/20 1:52 PM MDT
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 10/03/20 1:52 PM MDT
	Auscultated breath sounds in anterior right middle lobe	Exam Action 10/03/20 1:52 PM MDT
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 10/03/20 1:52 PM MDT
	Auscultated breath sounds in anterior right middle lobe	Exam Action 10/03/20 1:52 PM MDT
	Auscultated breath sounds in anterior right lower lobe	Exam Action 10/03/20 1:53 PM MDT
	Auscultated breath sounds in anterior left lower lobe	Exam Action 10/03/20 1:53 PM MDT
	Auscultated breath sounds in posterior right upper lobe	Exam Action 10/03/20 1:53 PM MDT
	Auscultated breath sounds in posterior left upper lobe	Exam Action 10/03/20 1:53 PM MDT
	Auscultated breath sounds in posterior left mid-back (lower lobe)	Exam Action 10/03/20 1:53 PM MDT
	Auscultated breath sounds in posterior right mid-back (lower lobe)	Exam Action 10/03/20 1:53 PM MDT
	Auscultated breath sounds in posterior left lower lobe near spine	Exam Action 10/03/20 1:53 PM MDT
	Auscultated breath sounds in posterior right lower lobe near spine	Exam Action 10/03/20 1:53 PM MDT
	Auscultated breath sounds in posterior right lower lobe	Exam Action 10/03/20 1:54 PM MDT
	Auscultated breath sounds in posterior left lower lobe	Exam Action 10/03/20 1:54 PM MDT
	Auscultated breath sounds in posterior left lower lobe on side	Exam Action 10/03/20 1:54 PM MDT
	Auscultated breath sounds in posterior right lower lobe on side	Exam Action 10/03/20 1:54 PM MDT
	Auscultated breath sounds in anterior left upper lobe	Exam Action 10/03/20 1:54 PM MDT
	Auscultated breath sounds in anterior right upper lobe	Exam Action 10/03/20 1:54 PM MDT
	Auscultated breath sounds in anterior right middle lobe	Exam Action 10/03/20 1:54 PM MDT
	Auscultated breath sounds in anterior left mid-chest (upper lobe)	Exam Action 10/03/20 1:54 PM MDT
	Auscultated breath sounds in anterior right middle lobe	Exam Action 10/03/20 1:54 PM MDT
	Auscultated breath sounds in anterior right lower lobe	Exam Action 10/03/20 1:54 PM MDT
	Percussed anterior right upper lobe	Exam Action 10/03/20 1:55 PM MDT
	Percussed anterior left upper lobe	Exam Action 10/03/20 1:55 PM MDT
	Percussed anterior right middle lobe	Exam Action 10/03/20 1:55 PM MDT
	Percussed anterior left mid-chest (upper lobe)	Exam Action 10/03/20 1:55 PM MDT
	Percussed anterior left lower lobe	Exam Action 10/03/20 1:55 PM MDT
	Percussed anterior right lower lobe	Exam Action 10/03/20 1:55 PM MDT
	Percussed posterior right upper lobe	Exam Action 10/03/20 1:55 PM MDT
	Percussed posterior left upper lobe	Exam Action 10/03/20 1:55 PM MDT
	Percussed posterior left mid-back (lower lobe)	Exam Action 10/03/20 1:55 PM MDT
	Percussed posterior right mid-back (lower lobe)	Exam Action 10/03/20 1:55 PM MDT
	Percussed posterior right lower lobe	Exam Action 10/03/20 1:55 PM MDT
	Percussed posterior right lower lobe near spine	Exam Action 10/03/20 1:56 PM MDT
	Percussed posterior left right lobe on side	Exam Action 10/03/20 1:56 PM MDT
	Percussed posterior left lower lobe near spine	Exam Action 10/03/20 1:56 PM MDT
	Percussed posterior left lower lobe	Exam Action 10/03/20 1:56 PM MDT
	Percussed posterior left lower lobe on side	Exam Action 10/03/20 1:56 PM MDT
	Percussed posterior left lower lobe on side	Exam Action 10/03/20 1:56 PM MDT
	Percussed posterior left lower lobe on side	Exam Action 10/03/20 1:56 PM MDT
	Checked vitals	Exam Action 10/03/20 1:56 PM MDT
	Do you have sick friends ?	Question 10/03/20 5:03 PM MDT
	None of my friends are sick that I know of.
	Do you have anybody passing it around you ? (No matching questions found.)	Question 10/03/20 5:04 PM MDT
	Do you have your friend Tony coughing around you ? (Clarified to Is tony sick?.)	Question 10/03/20 5:04 PM MDT
	None of my friends are sick that I know of. (Clarified to if Tony is sick.)
	Are you touching your nose ? (No matching questions found.)	Question 10/03/20 5:05 PM MDT
	How often do you touch your nose ? (Clarified to How often do you blow your nose?.)	Question 10/03/20 5:05 PM MDT
	Probably a million-billion times a day. [AUDIO COMING SOON] (Clarified to how often I blow my nose.)
	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. NURS 6512 Week 5 – Focused Exam: Cough Danny Rivera	Educate 10/03/20 5:10 PM MDT
	Oh, OK.
	Is anybody in your class sick ?	Question 10/03/20 5:35 PM MDT
	Nobody I know is sick, I don’t think.
	How is the Tony feels ?	Question 10/03/20 5:36 PM MDT
	None of my friends are sick that I know of.
	What type of diet do you have ?	Question 10/03/20 5:39 PM MDT
	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.
	What do you like to eat for breakfast ?	Question 10/03/20 5:39 PM MDT
	I have cereal with milk and fruit most mornings. Sometimes I have a waffle or eggs and bacon.
	Do you do exercises ?	Question 10/03/20 5:39 PM MDT
	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]
	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
	Oh, OK.
	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
	Oh, OK.
	Inspected mouth	Exam Action 10/04/20 3:15 AM MDT
	Can I take a look at your mouth again ?	Question 10/04/20 3:16 AM MDT
	Sure.
	Performed otoscopic examination of right ear	Exam Action 10/04/20 3:17 AM MDT
	Can I examine you more Danny ?	Question 10/04/20 3:18 AM MDT
	Sure.
	Performed otoscopic examination of left ear	Exam Action 10/04/20 3:18 AM MDT
	Performed otoscopic examination of right ear	Exam Action 10/04/20 3:18 AM MDT
	Performed otoscopic examination of left ear	Exam Action 10/04/20 3:19 AM MDT
	Inspected mouth	Exam Action 10/04/20 3:29 AM MDT
	Danny how often you washing your hands ?	Question 10/04/20 1:37 PM MDT
	I wash my hands before I eat or after I go to the bathroom.
	You need to wash your hands more often or to use hand sanitizer.	Educate 10/04/20 1:38 PM MDT
	Oh, OK.
	Do you play with a sick peer ?	Question 10/04/20 1:38 PM MDT
	I have a lot of girls that are friends, but no girlfriends really. Not yet! There are some girls I think are pretty though.
	When your cough started ?	Question 10/04/20 1:39 PM MDT
	I think the cough started four. . . No, it started five days ago.
	Where do you have your pain ?	Question 10/04/20 1:40 PM MDT
	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.
	Do you have any discharge from your right ear ?	Question 10/04/20 1:41 PM MDT
	No, nothing comes out of my ears, but my right ear kind of hurts.
	Do you have sore throat ?	Question 10/04/20 1:41 PM MDT
	It feels a little bit sore, yeah.
	How would you describe your pain ?	Question 10/04/20 1:41 PM MDT
	Um. . . I don’t know. It just hurts. But it’s not so bad.
	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
	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.)
	Do you take something for pain ? (Clarified to Are you taking anything for pain?.)	Question 10/04/20 1:42 PM MDT
	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.)
	Who is Abuela ?	Question 10/04/20 1:42 PM MDT
	Abuela is my grandma . . . she’s my mom’s mom!
	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
	Did you say your pain like watery and gurgle ? (No matching questions found.)	Question 10/04/20 1:43 PM MDT
	Did you say that your pain pills like watery ? (No matching questions found.)	Question 10/04/20 1:44 PM MDT
	How was your pain in your throat feels like ?	Question 10/04/20 1:44 PM MDT
	Um, it just feels kind of sore. I can feel it a little bit when I swallow.
	Oh, I am sorry to hear that Danny.	Empathize 10/04/20 1:46 PM MDT
	Thank you.
	Danny how much water do you take ?	Question 10/04/20 1:59 PM MDT
	I drink water a lot. . . whenever I’m not drinking it enough, Abuela always makes me drink more.
	How many cups of water do you drink per day ?	Question 10/04/20 2:00 PM MDT
	I usually have 7 or 8 glasses of water a day.
	Is Tony used uses an inhaler ? (Clarified to Is Tony your brother?.)	Question 10/04/20 2:07 PM MDT
	Tony’s my best friend. (Clarified to if Tony is my brother.)
	Do you know is Tony uses inhaler	Question 10/04/20 2:08 PM MDT
	None of my friends are sick that I know of.
	Danny you need to stay away from sick people ok ?	Educate 10/04/20 5:05 PM MDT
	Oh, OK.
	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
	Oh, OK.
	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
	Oh, OK.
	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
	Oh, OK.
	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
	Oh, OK.
	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
	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
	Oh, OK.
	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
	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
	Oh, OK.
	Do you have a pain now ? (Clarified to Do you have pain right now?.)	Question 10/04/20 5:27 PM MDT
	The only thing that really hurts is my right ear, but it just hurts a little bit. It just started . . . I’m not sure what will make it feel better. (Clarified to if I am in pain right now.)
	I’m sorry to hear that	Empathize 10/04/20 5:27 PM MDT
	Thank you.
	How often do you said you are coughing ?	Question 10/04/20 5:27 PM MDT
	I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
	I’m sorry it must be really uncomfortable.	Empathize 10/04/20 5:28 PM MDT
	Thank you.
	What type of medication are you taking for your cough ?	Question 10/04/20 5:47 PM MDT
	I took some cough medicine this morning. [AUDIO COMING SOON]
	What type of medication is this ? (Clarified to What medications do you take?.)	Question 10/04/20 5:47 PM MDT
	I took some cough medicine this morning. [AUDIO COMING SOON] (Clarified to what medications I am taking.)
	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
	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.)
	do you know the name of the medication for the cough ?	Question 10/04/20 5:49 PM MDT
	I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON]
	ok, I can ask your mom about it. (No matching questions found.)	Question 10/04/20 5:49 PM MDT
	How long does medication was relieving your symptoms ? (No matching questions found.)	Question 10/04/20 5:50 PM MDT
	How long does cough medication was relieving your symptoms ?	Question 10/04/20 5:50 PM MDT
	My mom gave me some medicine and it helped my cough a little bit, but it started again.
	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
	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.)

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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

Established chief complaint

Reports cough

History of Present Illness

Asked about onset of cough

Reports cough started 5 days ago

Asked about frequency and duration of cough

Reports coughing every few minutes

Asked about character of cough

Reports cough is wet

Reports clear sputum

Asked about aggravating factors for cough

Reports cough is worse at night

Reports exposure to secondhand smoke

Denies knowing what makes the cough worse

Asked about relieving factors for cough

Denies resting relieves cough

Denies drinking water relieves cough

Asked about nasal symptoms

Reports current runny nose

Denies sneezing

Reports frequent runny nose

Followed up on nasal discharge

Reports nasal discharge is clear

Reports nasal discharge is thin

Asked about ear symptoms

Reports pain in right ear

Followed up on ear pain

Reports ear pain started yesterday

Reports ear pain is a 3 out of 10

Denies ear discharge

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Asked about throat symptoms

Reports sore throat

Reports “a little” pain with swallowing

Asked about allergies

Denies seasonal allergies

Denies food allergies

Denies medication allergies

Denies allergies to animals

Denies latex allergy

Asked about contact with illnesses

Denies being around anyone ill at home

Home Medications

Asked about home medications

Confirmed home medications

Reports taking a daily vitamin

Reports taking cough medicine

Followed up on cough medicine

Reports cough medicine was purple

Reports taking one spoonful of cough medicine

Reports mother gave him the medicine

Reports cough medicine provided temporary relief

Past Medical History

Asked about relevant medical history

Denies asthma diagnosis

Reports immunizations as current

Reports past pneumonia and frequent coughs

Denies past hospitalizations

Social Determinants of Health

Asked about exposure to secondhand smoke

Reports father smokes cigars

Reports father sometimes forgets to take cigars outside

Social History

Asked about living conditions

Reports living in a house with parents and grandparents

Reports feeling safe at home

Reports park with playground near home

Review of Systems

Asked about constitutional health

Denies fever

Denies chills

Reports feeling “kind of tired”

Denies night sweats

Denies weight loss

Denies appetite loss

Asked about review of systems for HEENT

Denies ear popping or crackling

Reports history of frequent ear infections

Denies ear surgery or ear tubes

Denies headaches

Denies nosebleeds

Denies vision problems

Denies dizziness

Denies watery eyes

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Denies eye redness

Denies eye pain

Denies sinus pain

Denies hearing problems

Asked about review of systems for respiratory

Denies difficulty breathing

Denies chest tightness

Denies chest pain

Denies history of inhaler use or breathing treatments

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

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

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

2 Medications

Not Followed Up

	Description: Danny describes the medication he was given for his cough.
	What helps you cough ?	Question 01:01 PM MDT
	I had some cough medicine this morning. [AUDIO COMING SOON]
	Resting helps you ? (Clarified to: Does rest relieve your cough?)	Question 01:03 PM MDT
	My cough has just stayed the same. I’ve taken some naps, but it doesn’t seem to help. (Clarified to: if rest relieves my cough)
	Does drinking water helps your cough ?	Question 01:03 PM MDT
	Drinking water doesn’t do anything to my cough.
	Model Statement: “Thanks for telling me what you know about the medications you take. I can ask your mom or your abuela for more information.”

3 Vitamins

Followed Up

	Description: Danny describes taking vitamins.
	You take vitamins ? (Clarified to: Do you take a multivitamin every day?)	Question 01:12 PM MDT
	Oh yeah, I take vitamins every day! The gummy dinosaur kind. I don’t think I’m supposed to, but sometimes I sneak extra ones to be super healthy! (Clarified to: if I take a vitamin every day)
	It’s not good to take the extra one because it is important medication or vitamins dosages and the excess amount may hurt you.	Educate 01:14 PM MDT
	Oh, OK.
	Model Statement: “You’re right; taking vitamins can be good for you. However, sometimes taking too many vitamins can be bad for you. It’d be better if you don’t sneak extra vitamins — just take the amount that your mom gives you.”

4 Secondhand Smoke

Followed Up

	Description: Danny describes exposure to secondhand smoke at home.
	Do you smoke ?	Question 12:52 PM MDT
	No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell.
	Is Papi smokes at home around you ?	Question 12:54 PM MDT
	Yeah, sometimes Papi smokes cigars inside. He forgets to take them outside and my mom has to remind him. [AUDIO COMING SOON]
	It’s called secondary smoke When someone at home smokes they need to go to outside. Please dont be around the people who smoking. It is called secondary smoke. If you see somebody smoking and have no intentions to leave or you coming to the place where somebody smoked please do not stay in the same area. You need to leave. It is called secondary smoking and may affect your lungs when you inhale the smoke.	Educate 01:00 PM MDT
	Oh, OK.
	Model Statement: “That’s too bad your Papi smokes cigars at home. It sounds like it bothers you. Breathing in smoke isn’t very healthy, so it’s good to stay out rooms where you can smell cigar smoke.”

5 Family History

Not Followed Up

	Description: Danny describes what he knows about his family health history.
	Is anybody sick in your house ?	Question 01:28 PM MDT
	Nobody at home is sick I don’t think.
	Do you have any family history of asthma ?	Question 01:28 PM MDT
	Mom says Papi had asthma when he was a little kid.
	Anybody in your family has allergies ?	Question 01:28 PM MDT
	I don’t think so, but I guess I’m not sure.
	Do you have any pets at home ?	Question 01:29 PM MDT
	No, but I keep asking my mom if I can get a lizard.
	What do you do when you have a free time ?	Question 01:30 PM MDT
	Usually I play video games or read or try to write stories. If Tony is here, we do that stuff together.
	Model Statement: “Thanks for telling me what you know about your family history. You did a good job remembering.”

Comments

Document: Vitals
Document: Provider Notes

Document: Vitals

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

NURS 6512 Week 5 Focused Exam Cough Danny Rivera