Chamberlain College of Nursing - NR 509Focused Exam- Cough |Transcript. Advanced Health Assessment - Chamberlain, NR509-April-2018. LAB PASS.

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FOCUSED EXAM Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 1/21 Focused Exam: Cough Results | Turned In Advanced Health Assessment - Chamberlain... , NR509-April-2018 Return to Assignment Your Results L La ab b P Pa as ss s Started: Jun 04, 2018 | Patient Exam Time: 86 min I In nt te er rv viie ew w Q Qu ue es st tiio on ns s ( (7 76 6) ) S St ta at te em me en nt ts s ( (8 8) ) E Ex xa am m A Ac ct tiio on ns s ( (9 96 6) ) Hello, My name is Sara an FNP student and I will be interviewing you today Hi. What brought you into the clinic today? My Abuela brought me here because I've been feeling sick. I have been coughing a lot. . . and I feel kinda tired. What is your name? My name is Daniel Rivera, but I just go by Danny. And how old are you? I'm eight. What is your date of birth? I was born March 4th in, um . . . [Danny reports correct birth year.] [AUDIO COMING SOON] A Allll L Liin ne es s ( (1 18 80 0) )6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 2/21 When did your cough start? I think the cough started four. . . No, it started five days ago. Can you describe your place to me? My cough seems kind of gurgly and watery. Do you have any sputum? 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. How often are you coughing? I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night. How long does a cough last? 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?.) My cough seems kind of gurgly and watery. What makes your cough worse?6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 3/21 My cough mostly stays the same no matter what I do. It seems to get worse at night though. Do you smoke? My cough mostly stays the same no matter what I do. It seems to get worse at night though. Are you exposed to anyone smoking? 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. Does your father smoke? smoking, make sure you're around no one that is smoking Oh, OK.6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 4/21 What type of cough medicine do you take? (Clarified to Can you describe the cough medicine to me.) Um, it was purple-ish. It tasted gross. Do you know how much cough medicine you take? I just had one spoonful of it. Who gives you the medication? My mom. Any other things you were doing for your cough? 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. Are you using any home remedies for your cough? I had some cough medicine this morning. [AUDIO COMING SOON] Home remedies for cough? I had some cough medicine this morning. [AUDIO COMING SOON] Are you taking anything else for your cough? (Clarified to are you taking other medications.) I'm not taking any medicines every day. My mom gave me some cough medicine this morning though. Do you typically take medication every day? (Clarified to do you take any medications daily.)6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 5/21 I don't take any medicines every day. Do you take a vitamin? 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! You really should only take one as prescribed on the bottle of gummy dinosaurs Oh, OK. How is your activity level? I have gym class every day. I do all my exercises there. Abuela chool? (No matching questions found.) how is your school focus? I like school, but I guess sometimes it makes me feel bored if the homework is too easy. With your cough are you still able to play? (No matching questions found.)6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 6/21 Is your cough interfering with your play I don't usually wake up once I go to bed, but my cough has made it hard to fall asleep. Does your cough make it difficult to run? I don't usually wake up once I go to bed, but my cough has made it hard to fall asleep. How is your activity level? I have gym class every day. I do all my exercises there. Abuela always has to remind me to play outside for a little bit on the What color is your nasal discharge?6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 7/21 You mean like when I blow my nose? It's clear. Is the drainage from your nose thin? My nose is always a little bit runny... but ever since I started coughing it's been worse, I think. What is the consistency of your nasal drainage? It's kind of clear and, like, watery. Are you having any pain? Nothing really hurts. I've just had this cough for about five days. . . and I feel kind of tired. On a Pain Scale of 0 to 10 what would you rate your pain? Well, I have a little pain . . . in my right ear. Maybe almost a 3. Yeah. It's not too bad. I'm sorry you're in pain Thank you. Are you having pain in your ears? My right ear is starting to hurt a little bit . . . my left one is OK though. history of ear infections? (Clarified to have you ever had ear infections.)6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 8/21 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 . . . Do you have any ear drainage? No, nothing comes out of my ears, but my right ear kind of hurts. I'm sorry to hear that Thank you. Do you have any hearing problems? 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 . . . When did you have your hearing test? (Clarified to when was the last time you had your hearing tested.) A lady came to school this year to give us a hearing test. Maybe a month ago? I was hoping I would have super hearing, but it was just normal. . . Do you have a sore throat? It feels a little bit sore, yeah. Does it hurt to swallow? No, I can swallow OK. It hurts a little right now because my throat is kinda sore. I'm sorry your throat hurt.6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 9/21 . Do you have a history of asthma? Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don't have to. Are your immunizations current? 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. Have you ever had pneumonia? I think I had that last year, when I was seven. My mom was really worried. Do you have a history of frequent cough? I sometimes get coughs like this, but it's not all the time. I don't think it's a lot. I coughed a lot was when I had pneumonia one time. Do you have seasonal allergies? I don't think I have any allergies like that. Do you have any food allergies? I'm not allergic to any foods I don't think. Do you have any medication allergies? I don't think I'm allergic to medicine.6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 10/21 Have you had any fever? My mom said I didn't have a fever this morning before Abuela took me here. Is your activity the same with your cough? (Clarified to Does activity make your cough worse?.) I don't think so. My cough stays the same. I just felt tired during o go to the clinic at night instead of my regular doctor. Mom was really worried, but it got better after some rest and medicine. Does your father have a history of asthma? (Clarified to does your father have health problems.) Papi has sometimes says his blood pressure is high. He always says he has to watch his cholesterol too. Oh, he smokes too. I know that's bad for him. . . Mom tells him not to because he had asthma when he was a little kid. Any family history of allergies? I don't think so, but I guess I'm not sure.6/4/2018 Focused Exam: Cough | Completed | Shadow Health Tested lung capacity with spirometer: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%) Inspected left orbital area and sclera Inspected right orbital area and sclera Performed otoscopic examination of right ear Performed otoscopic examination of left ear Performed otoscopic examination of right ear Performed otoscopic examination of left ear6/4/2018 Focused Exam: Cough | Completed | Shadow Health outh Inspected front of neck Inspected left side of neck Inspected back of neck Inspected right side of neck Inspected front of neck Inspected mouth Inspected mouth Palpated frontal sinuses: No tenderness reported Palpated maxillary sinuses: No tenderness reported6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 13/21 ervical lymph nodes: Enlarged and reported tenderness on the right side Palpated supraclavicular lymph nodes: Not palpable Palpated axillary lymph nodes: Not palpable Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally Ninety-nine. Auscultated breath sounds in anterior right middle lobe Auscultated breath sounds in posterior right upper lobe Auscultated breath sounds in posterior right mid-back (lower lobe) Auscultated breath sounds in posterior left mid-back (lower lobe) Auscultated breath sounds in posterior left lower lobe on side6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 15/21 anterior right upper lobe Ninety-nine. Auscultated voice sounds in anterior right middle lobe Auscultated voice sounds in anterior left mid-chest (upper lobe) Auscultated voice sounds in anterior left lower lobe Ninety-nine. Auscultated voice sounds in posterior left upper lobe Ninety-nine. Ninety-nine. Auscultated voice sounds in posterior right upper lobe Auscultated voice sounds in posterior left lower lobe Auscultated voice sounds in posterior left lower lobe on side Auscultated voice sounds in posterior right lower lobe near spine Auscultated aortic area with the bell gm Auscultated pulmonic area with the bell Auscultated Erb's point with the bell Auscultated mitral area with the bell Auscultated mitral area with the diaphragm6/4/2018 Focused Exam: Cough | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3552952 18/21 Exam Action Percussed anterior left upper lobe Percussed anterior left mid-chest (upper lobe) Percussed anterior right middle lobe lobe) Percussed posterior left lower lobe Percussed posterior right lower lobe Percussed posterior left right lobe on side6/4/2018 Focused Exam: Cough | Completed | Shadow Health d posterior right lower lobe near spine Percussed posterior left lower lobe near spine No, I haven't felt that. Any fever? My mom said I didn't have a fever this morning before Abuela took me here. night sweats? I don't sweat at night unless it gets really hot or something. Are you having any headaches? I don't usually get headaches. Any nose bleeds? Just one time. Tony and I were kicking a ball at recess and I got hit in the nose. No, I see really good. Oh, I mean, I see well. I think glasses are kind of cool though. My friend Tony has them. Any watery eyes? No, my eyes don't tear up. Well, I guess if I get sad or Papi is chopping onions for dinner they might. ?having any eye redness I don't think my eyes are ever red. Any eye pain? No, my eyes don't hurt, but they kind of feel like they do when I'm tired. Any sinus pain? No, I don't have pain in my chest. I would hate that! Comments If your instructor provides individual feedback on this assignment, it will appear here. [Show More]

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