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Pediatric Assignment Results | Completed Your text here 1
Advanced Health Assessment - January 2020, NR509-December-2019
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Overview
Transcript
Transcript
Started: Feb 17, 2020 | Total Time: 93 min
Subjective Data Collection
All Lines (230) Interview Questions (125) Statements (12) Exam Actions (93)
Objective Data Collection
Education & Empathy Gree
Hi danny! My name is sheralee and im going to be performing your assessment today
02/17/20 12:18 PM CS
Documentation
Self-Reflection Hi.
Student Survey
Questio
What brought you in today?
02/17/20 12:18 PM CS
My Abuela brought me here because I've been feeling sick. I have been coughing a lot. . . and
I feel kinda tired.
Empathiz
im so sorry to hear that, im going to do whatever I can to help you
02/17/20 12:19 PM CS
Thank you.
Questio
Did your car start (No matching questions found.)
02/17/20 12:20 PM CS
Questio
Did your cough start (Clarified to When did the cough start?.)
02/17/20 12:20 PM CS
I think the cough started four. . . No, it started five days ago. (Clarified to when the cough
started.)
Questio
Is it a dry cough
02/17/20 12:20 PM CS
No . . . my cough seems kind of gurgly and watery.
, Questio
Where is your cough coming from
02/17/20 12:22 PM CS
I don't feel like coughing now really. It just keeps happening sometimes.
Questio
Where is your cough?
02/17/20 12:22 PM CS
It's just a normal house. It's, um, blue on the outside. It has two floors and a basement. My
bedroom is upstairs! Mama and Papi live upstairs with me, Abuelo and Abuela live downstairs.
Papi is going to work on the basement soon. [AUDIO COMING SOON]
Questio
do you have any other symptoms?
02/17/20 12:22 PM CS
My nose is a runny and I just feel kind of tired. Oh . . . my throat hurts a little bit too. But just a
little bit.
Empathiz
im sorry to hear that
02/17/20 12:23 PM CS
Thank you.
Questio
have you had a fever?
02/17/20 12:23 PM CS
My mom said I didn't have a fever this morning before Abuela took me here.
Questio
what is the location of your cough?
02/17/20 12:23 PM CS
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.
Questio
how long does your cough last?
02/17/20 12:23 PM CS
I think the cough started four. . . No, it started five days ago.
Questio
Does anything make your cough worse?
02/17/20 12:24 PM CS
My cough mostly stays the same no matter what I do. It seems to get worse at night though.
Questio
does anything make your cough better?
02/17/20 12:24 PM CS
I haven't taken anything except the cough medicine my mom gave me. It helped a little, but
then my cough started up again.
Questio
does anything else make your cough better?
02/17/20 12:25 PM CS
I haven't taken anything except the cough medicine my mom gave me. It helped a little, but
then my cough started up again.
What kind of cough medicine do you take? (Clarified to What is the name of the cough Questio
medicine you took?.) 02/17/20 12:25 PM CS
, 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.)
Questio
do you know how much cough medicine you took?
02/17/20 12:25 PM CS
She just gave me one spoonful of it.
Questio
how often did you take the cough medicine?
02/17/20 12:26 PM CS
I only took the cough medicine once. My mom gave me a spoonful. [AUDIO COMING SOON]
Questio
do you take any other medication?
02/17/20 12:26 PM CS
I'm not taking any medicines every day. My mom gave me some cough medicine this morning
though.
Questio
did the cough medicine help?
02/17/20 12:26 PM CS
It helped a bit when my mom gave it to me, but my cough came back anyway.
Questio
do you take any vitamins?
02/17/20 12:27 PM CS
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!
Questio
how many vitamins do you take each day?
02/17/20 12:27 PM CS
I don't know. A couple more? [AUDIO COMING SOON]
Questio
how long have you taken the vitamins?
02/17/20 12:27 PM CS
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!
Questio
do you have any allergies?
02/17/20 12:28 PM CS
I don't really have any allergies. Tony has some though. He's allergic to bees.
Questio
who is tony?
02/17/20 12:28 PM CS
Tony's my best friend.
Questio
how tall are you?
02/17/20 12:28 PM CS
I'm almost four feet... and two inches. Papi sometimes marks how tall I am at home.