Experience Overview: FOCUSED EXAM: COUGH PatientWalden UniversityNRNP 509Cough

Patient: Danny Rivera Digital Clinical Experience Score 100% Beginning Developing Proficient Subjective Data Collection 20 out of 20 Objective Data Collection 12.8 out of 13 Education and Empathy 3 out of 5 Interaction with patient 287 minutes Post-exam activities 22 minutes Time 309 minutes total spent in assignment Student Performance Index 35.8 out of 38 Proficiency Level: Proficient Students rated as “proficient” demonstrate an entrylevel expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient Student Documentation Model Documentation Subjective CC: Cough HPI Onset: 4-5 days ago Location: right ear pain Duration: "a couple of minutes" Characteristics: sore throat (mild), fatigue Aggravating factors: night time Relieving factors: cough syrup Treatment: OTC cough syrup Current medications: multivitamins and cough syrup Allergies: none PMHx: pneumonia, frequent ear infections during early childhood Social Hx: The patient lives with his mother, father, and maternal grandmother and grandfather. Father sometimes smoke in the house. Family Hx: Father had asthma as a child and is a current positive smoker. Maternal grandfather also has a smoking history and diagnosed with eczema. ROS Constitutional: Positive for fatigue related to cough that keeps him up at night. Denies night sweats, fevers, chills, and weight loss. HEENT: Denies headaches and dizziness. Denies nosebleeds. Positive for right ear pain. Denies ear drainage. Positive for clear nasal discharge. Denies eye redness, watery eyes, eye pain and visual disturbances. Positive for sore throat. Cardiac: Denies chest pain and tightness Resp: Positive for dry cough. Denies shortness of breath. GI: Denies nausea, vomiting, diarrhea. Denies abdominal pain and discomfort. Last BM was today before school. C” He