NR 509 Focused Exam- Cough |Transcript . GRADED A+

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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Overview
Transcri
pt
Transcript Started: Jun 04, 2018 | Patient Exam Time: 86 min

Subjective Data Collection
All Lines Interview Questions Statements Exam Actions
Objective Data Collection (180) (76) (8) (96)

Education & Empathy
Greet
Hello, My name is Sara an FNP student and I will be interviewing
06/04/18 2:50 PM
Documentation you today
CDT

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 06/04/18 2:52 PM
you? 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, tho




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.



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




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




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 bre




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


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



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


Oh, OK.




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