NR 509 Shadow Health Focused Exam Cough-Objective Data

6/4/2018 Focused Exam: Cough | Completed | Shadow Health


Focused Exam: Cough Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Your Results Lab Pass




Overview
Transcript
Transcript
Started: Jun 04, 2018 | Patient Exam Time: 86 min
Subjective Data Collection
All Lines (180) Interview Questions (76) Statements (8) Exam Actions (96)
Objective Data Collection
Greet
Education & Empathy Hello, My name is Sara an FNP student and I will be interviewing you
06/04/18 2:50 PM
today
CDT
Documentation

Self-Reflection
Hi.


Question
What brought you into the clinic today? 06/04/18 2:51 PM
CDT


My Abuela brought me here because I've been feeling sick. I have
been coughing a lot. . . and I feel kinda tired.


Question
What is your name? 06/04/18 2:52 PM
CDT



My name is Daniel Rivera, but I just go by Danny.


Question
And how old are you? 06/04/18 2:52 PM
CDT



I'm eight.


Question
What is your date of birth? 06/04/18 2:52 PM
CDT


I was born March 4th in, um . . . [Danny reports correct birth year.]
[AUDIO COMING SOON]




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,6/4/2018 Focused Exam: Cough | Completed | Shadow Health

I'm sorry you feel so bad Empathize
06/04/18 2:54 PM
CDT



Thank you.


Question
When did your cough start? 06/04/18 2:55 PM
CDT



I think the cough started four. . . No, it started five days ago.


Question
Can you describe your place to me? 06/04/18 2:55 PM
CDT



My cough seems kind of gurgly and watery.


Question
Do you have any sputum? 06/04/18 2:56 PM
CDT


Is that the gross, slimy stuff? Yeah, I've been coughing some of that
up. It's not any strange color, though. It's just clear.


Question
How often are you coughing? 06/04/18 2:59 PM
CDT


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


Question
How long does a cough last? 06/04/18 2:59 PM
CDT



I think the cough started four. . . No, it started five days ago.


Question
What is the duration of your cough? (Clarified to How would you
06/04/18 3:00 PM
describe your cough?.)
CDT



My cough seems kind of gurgly and watery.


Question
What makes your cough worse? 06/04/18 3:00 PM
CDT




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, 6/4/2018 Focused Exam: Cough | Completed | Shadow Health

My cough mostly stays the same no matter what I do. It seems to
get worse at night though.


Question
Do you smoke? 06/04/18 3:01 PM
CDT


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


Question
Do you know what triggers your cough? (No matching questions
06/04/18 3:01 PM
found.)
CDT


Question
What makes your cough worse? 06/04/18 3:01 PM
CDT


My cough mostly stays the same no matter what I do. It seems to
get worse at night though.


Question
Are you exposed to anyone smoking? 06/04/18 3:02 PM
CDT


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.


Question
Does your father smoke? 06/04/18 3:02 PM
CDT


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.


Question
What makes your cough better? 06/04/18 3:03 PM
CDT



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


Educate
Being exposed to secondhand smoke is almost just as bad as
06/04/18 3:03 PM
smoking, make sure you're around no one that is smoking
CDT



Oh, OK.




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