shadow health cough documentation
Name:
Section:
Week 5
Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
Significant Family History (Include history of parents, Grandparents, siblings, and children):
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Psychiatric:
Neurological:
Lymphatics:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see.
Physical Exam:
Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
HEENT:
Respiratory: Always include this in your PE.
Cardiology: Always include the heart in your PE.
Lymphatics:
Psychiatric:
Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.
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2
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Week 5 – Focused Exam: Cough, Danny Rivera – REQUIRED Results | Turned In
Advanced Health Assessment and Diagnostic Reasoning – NP – February 2022, nurs6512-laureate_higher_education_group-202250
Your Results
- Overview
- Transcript
- Subjective Data Collection
- Objective Data Collection
- Education & Empathy
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Documentation
- Program Competency Progress
Experience Overview
Patient:
Danny Rivera
Digital Clinical Experience Score
97.5%
This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.
Student Performance Index
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36.87 out of 39 |
Proficiency Level:
Proficient
Students rated as beginning are starting to develop their advanced practice competencies and clinical reasoning skills. In comparable programs, 50% of students perform at the level of a beginning practitioner. Review your results in the tabs on the left side of the page to identify areas for improvement.
Students rated as developing demonstrate increasing clinical reasoning abilities as they apply their knowledge of advanced practice competencies. In comparable programs, 25% of students perform at the level of a developing practitioner. Review your results in the tabs on the left side of the page to identify areas for improvement.
Students rated as proficient demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.
Subjective Data Collection
21
out of
21
Objective Data Collection
11.87
out of
13
Education and Empathy
4
out of
5
Time
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83 minutes total spent in assignment |
Interaction with patient
83 minutes
Transcript
Started:
Mar 29, 2022
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Total Time:
83 min
All Lines (122)
Interview Questions (79)
Statements (7)
Exam Actions (36)
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hello my name is Mary Sarfo and will be taking care of you and conducting your assessment . |
Greet 03/29/22 12:04 AM MDT |
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Hi. |
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what is your name |
Question 03/29/22 12:04 AM MDT |
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My name is Daniel Rivera, but I just go by Danny. |
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Hi Danny, how old are you? (Clarified to Hi, how are you?.) |
Question 03/29/22 12:04 AM MDT |
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My Abuela brought me here because I’ve been feeling sick. I have been coughing a lot. . . and I feel kinda tired. (Clarified to to say hello and ask how I am.) |
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I am sorry that you not feeling well |
Empathize 03/29/22 12:05 AM MDT |
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Thank you. |
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how old are you |
Question 03/29/22 12:05 AM MDT |
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I’m eight. |
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when is you birth date |
Question 03/29/22 12:05 AM MDT |
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I was born March 4th in, um . . . [Danny reports correct birth year.] |
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tell me what brings you in today |
Question 03/29/22 12:06 AM MDT |
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My Abuela brought me here because I’ve been feeling sick. I have been coughing a lot. . . and I feel kinda tired. |
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Do you have cough? |
Question 03/29/22 12:06 AM MDT |
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I guess I’m kind of sick. . . I’ve been coughing a lot. |
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when did the cough starts |
Question 03/29/22 12:07 AM MDT |
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I think the cough started four. . . No, it started five days ago. |
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how long have you had cough |
Question 03/29/22 12:07 AM MDT |
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I think the cough started four. . . No, it started five days ago. |
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tell me about how your cough is |
Question 03/29/22 12:08 AM MDT |
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I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night. |
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is your cough wet |
Question 03/29/22 12:08 AM MDT |
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Yeah . . . my cough seems kind of gurgly and watery. |
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how frequent do you cough |
Question 03/29/22 12:08 AM MDT |
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I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night. |
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how long do your cough last |
Question 03/29/22 12:09 AM MDT |
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I think the cough started four. . . No, it started five days ago. |
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what makes your cough worse |
Question 03/29/22 12:09 AM MDT |
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My cough mostly stays the same no matter what I do. It seems to get worse at night though. |
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is the cough worse at night? |
Question 03/29/22 12:10 AM MDT |
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Yeah, my cough’s worse at night. |
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does your cough wakes you at night |
Question 03/29/22 12:10 AM MDT |
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I can’t fall asleep much because I keep coughing. |
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do you smoke |
Question 03/29/22 12:11 AM MDT |
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No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell. |
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are you ever around cigarette smoke |
Question 03/29/22 12:12 AM MDT |
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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. |
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have you done anything to treat your cough? |
Question 03/29/22 12:12 AM MDT |
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I had some cough medicine this morning. [AUDIO COMING SOON] |
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what name was the cough medicine |
Question 03/29/22 12:13 AM MDT |
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I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON] |
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what color was the cough medicine |
Question 03/29/22 12:14 AM MDT |
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Um, it was purple-ish. It tasted gross. |
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how much cough medicine did you take |
Question 03/29/22 12:14 AM MDT |
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I just had one spoonful of it. |
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who gave you the cough medication |
Question 03/29/22 12:15 AM MDT |
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My mom. |
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how many times have you taken the cough syrup |
Question 03/29/22 12:15 AM MDT |
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I only took the cough medicine once. My mom gave me a spoonful. [AUDIO COMING SOON] |
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did it help with the cough (No matching questions found.) |
Question 03/29/22 12:16 AM MDT |
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did it help with the cough (No matching questions found.) |
Question 03/29/22 12:17 AM MDT |
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did it help with the cough (No matching questions found.) |
Question 03/29/22 12:17 AM MDT |
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have you try any home remedies for your cough |
Question 03/29/22 12:18 AM MDT |
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I had some cough medicine this morning. [AUDIO COMING SOON] |
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do you take any medications from a doctor |
Question 03/29/22 12:18 AM MDT |
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No. [AUDIO COMING SOON] |
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do you take any vitamins |
Question 03/29/22 12:18 AM MDT |
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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! |
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taking too much vitamins can cause other health issues |
Educate 03/29/22 12:19 AM MDT |
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Oh, OK. |
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what other OTC do you take |
Question 03/29/22 12:20 AM MDT |
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Just when I’m sick and my mom or the doctor says I should take some medicine. My mom gave me some cough medicine this morning. |
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are you active most of the time |
Question 03/29/22 12:20 AM MDT |
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I have gym class every day. I do all my exercises there. And there’s a park right next to my house where I play after school, or sometimes on the weekends, if it’s nice outside. [AUDIO COMING SOON] |
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have you been less active since you been sick (No matching questions found.) |
Question 03/29/22 12:21 AM MDT |
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have you been less active since you been sick (No matching questions found.) |
Question 03/29/22 12:21 AM MDT |
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are you less active now |
Question 03/29/22 12:22 AM MDT |
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No, I don’t feel nauseous. |
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has your activity changed since you been sick |
Question 03/29/22 12:22 AM MDT |
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I have gym class every day. I do all my exercises there. And there’s a park right next to my house where I play after school, or sometimes on the weekends, if it’s nice outside. [AUDIO COMING SOON] |
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are you able to keep up when you play with your classmates (No matching questions found.) |
Question 03/29/22 12:23 AM MDT |
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are you able to focus |
Question 03/29/22 12:23 AM MDT |
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I can focus normally, but I couldn’t sleep very well last night because of my coughing, so it was harder than normal. Plus, it’s harder to pay attention when you keep having to cough. [AUDIO COMING SOON] |
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do you have runny nose |
Question 03/29/22 12:24 AM MDT |
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My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think. |
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have you been sneezing |
Question 03/29/22 12:25 AM MDT |
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I don’t usually have to sneeze. My nose gets runny a lot of times though, like I have a cold. |
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what color is your snot |
Question 03/29/22 12:25 AM MDT |
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You mean like when I blow my nose? It’s clear. |
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what is the consistency of your nasal drainage |
Question 03/29/22 12:26 AM MDT |
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It’s kind of clear and, like, watery. |
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do you have any ear infection |
Question 03/29/22 12:27 AM MDT |
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I don’t know if it is infected, but my right ear kind of hurts. |
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sorry to hear that |
Empathize 03/29/22 12:27 AM MDT |
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Thank you. |
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do you have any drainage from your ears |
Question 03/29/22 12:27 AM MDT |
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No, nothing comes out of my ears, but my right ear kind of hurts. |
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do you have any hearing problems |
Question 03/29/22 12:28 AM MDT |
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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 . . . |
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do you have any sore throat |
Question 03/29/22 12:29 AM MDT |
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It feels a little bit sore, yeah. |
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does it hurts when you swallow |
Question 03/29/22 12:29 AM MDT |
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No, I can swallow OK. It hurts a little right now because my throat is kinda sore. |
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do you get runny nose often |
Question 03/29/22 12:31 AM MDT |
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My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think. |
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do you have coughs often (Clarified to Are you coughing a lot?.) |
Question 03/29/22 12:32 AM MDT |
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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. (Clarified to if I cough a lot.) |
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have you had pneumonia |
Question 03/29/22 12:32 AM MDT |
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I think I had that last year, when I was seven. My mom was really worried. |
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how did it get treated (No matching questions found.) |
Question 03/29/22 12:33 AM MDT |
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do you have asthma |
Question 03/29/22 12:33 AM MDT |
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Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don’t have to. |
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do you have asthma |
Question 03/29/22 12:33 AM MDT |
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Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don’t have to. |
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are you up to date on your immunizations? |
Question 03/29/22 12:34 AM MDT |
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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. |
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shots are good to protect you from illness |
Educate 03/29/22 12:35 AM MDT |
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Oh, OK. |
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do you have seasonal allergies |
Question 03/29/22 12:35 AM MDT |
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I don’t think I have any allergies like that. |
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do you have allergies to any medication |
Question 03/29/22 12:38 AM MDT |
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I don’t think I’m allergic to medicine. |
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any allergies to food |
Question 03/29/22 12:38 AM MDT |
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I’m not allergic to any foods I don’t think. |
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any family history of allergies |
Question 03/29/22 12:38 AM MDT |
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I don’t think so, but I guess I’m not sure. |
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any family history of asthma |
Question 03/29/22 12:39 AM MDT |
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Only Papi had asthma, I think. |
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do you have fever |
Question 03/29/22 12:39 AM MDT |
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My mom said I didn’t have a fever this morning before Abuela took me here. |
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do you have any chills |
Question 03/29/22 12:40 AM MDT |
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No, I haven’t felt that. |
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do you have fatigue |
Question 03/29/22 12:40 AM MDT |
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Yeah, I feel kind of tired. I think it’s because I couldn’t sleep much at night. My cough kept me from falling asleep. |
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sorry to hear that |
Empathize 03/29/22 12:40 AM MDT |
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Thank you. |
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do you have night sweats |
Question 03/29/22 12:41 AM MDT |
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I don’t sweat at night unless it gets really hot or something. |
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have you been sleeping okay |
Question 03/29/22 12:41 AM MDT |
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Most times I sleep OK, but I haven’t been able to sleep much because of my cough. |
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do you notice any swelling |
Question 03/29/22 12:41 AM MDT |
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Nothing’s swollen. |
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do you get frequent colds |
Question 03/29/22 12:42 AM MDT |
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I get colds a lot. My nose is always runny. |
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what medicine do you take for the runny nose (Clarified to Did you take medication for your runny nose?.) |
Question 03/29/22 12:42 AM MDT |
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I guess I don’t do anything for my nose. I make sure to keep a tissue around so I can blow it, but it still keeps running. (Clarified to if I took medication to treat my runny nose.) |
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do you have headaches |
Question 03/29/22 12:43 AM MDT |
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I don’t usually get headaches. |
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do you get nose bleeds |
Question 03/29/22 12:43 AM MDT |
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Just one time. Tony and I were kicking a ball at recess and I got hit in the nose. |
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sorry about that |
Empathize 03/29/22 12:44 AM MDT |
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Thank you. |
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do you have any vision problems |
Question 03/29/22 12:44 AM MDT |
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No, I see really good. Oh, I mean, I see well. I think glasses are kind of cool though. My friend Tony has them. |
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do you get dizzy |
Question 03/29/22 12:45 AM MDT |
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I only get dizzy if I’m spinning around a lot at recess. |
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do you have any sinus pain |
Question 03/29/22 12:45 AM MDT |
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It doesn’t hurt there. |
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do you have chest pain |
Question 03/29/22 12:45 AM MDT |
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No, I don’t have pain in my chest. I would hate that! |
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do you have any shortness of breath |
Question 03/29/22 12:46 AM MDT |
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My breathing seems good. My nose is kind of runny right now, but I can still breathe OK. |
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do you have any siblings |
Question 03/29/22 12:46 AM MDT |
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No, I’m the only kid in my house. |
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does your friend Tony gets runny nose too (Clarified to Is tony sick?.) |
Question 03/29/22 12:47 AM MDT |
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None of my friends are sick that I know of. (Clarified to if Tony is sick.) |
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Checked vitals |
Exam Action 03/29/22 12:48 AM MDT |
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Inspected right orbital area and sclera |
Exam Action 03/29/22 12:49 AM MDT |
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Inspected upper conjunctiva |
Exam Action 03/29/22 12:49 AM MDT |
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Inspected upper conjunctiva |
Exam Action 03/29/22 12:49 AM MDT |
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Inspected right orbital area and sclera |
Exam Action 03/29/22 12:49 AM MDT |
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Inspected left orbital area and sclera |
Exam Action 03/29/22 12:49 AM MDT |
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Inspected lower conjunctiva |
Exam Action 03/29/22 12:50 AM MDT |
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Performed otoscopic examination of right naris |
Exam Action 03/29/22 12:50 AM MDT |
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Performed otoscopic examination of left naris |
Exam Action 03/29/22 12:51 AM MDT |
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Performed otoscopic examination of right ear |
Exam Action 03/29/22 12:52 AM MDT |
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Performed otoscopic examination of left ear |
Exam Action 03/29/22 12:52 AM MDT |
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Inspected mouth |
Exam Action 03/29/22 12:53 AM MDT |
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Inspected front of neck |
Exam Action 03/29/22 12:54 AM MDT |
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Inspected right side of neck |
Exam Action 03/29/22 12:54 AM MDT |
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Inspected back of neck |
Exam Action 03/29/22 12:54 AM MDT |
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Inspected right side of neck |
Exam Action 03/29/22 12:55 AM MDT |
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Inspected front of neck |
Exam Action 03/29/22 12:55 AM MDT |
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Inspected anterior chest wall |
Exam Action 03/29/22 12:55 AM MDT |
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Inspected posterior chest wall |
Exam Action 03/29/22 12:55 AM MDT |
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does resting help your cough |
Question 03/29/22 1:57 AM MDT |
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My cough has just stayed the same. I’ve taken some naps, but it doesn’t seem to help. |
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does drinking water helps your cough |
Question 03/29/22 1:58 AM MDT |
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Drinking water doesn’t do anything to my cough. |
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how long have had ear pain |
Question 03/29/22 2:00 AM MDT |
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My right ear just started hurting yesterday. I think it’s because I’m sick. |
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Thanks for telling what you know about you and family history. That was a great job |
Question 03/29/22 2:02 AM MDT |
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My mom sometimes talks about her diabetes, cholesterol. . . Oh, and blood pressure. Papi talks about cholesterol too. He smokes too. I know that’s bad. |
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That is too bad your papi smokes at home. secondhand smoking is bad for health. I can tell you bothers you a lot. |
Empathize 03/29/22 2:04 AM MDT |
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Thank you. |
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Percussed anterior right upper lobe |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed anterior left upper lobe |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed anterior right middle lobe |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed anterior left mid-chest (upper lobe) |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed anterior right lower lobe |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed anterior left lower lobe |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed posterior left upper lobe |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed posterior right upper lobe |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed posterior left mid-back (lower lobe) |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed posterior right mid-back (lower lobe) |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed posterior left lower lobe |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed posterior right lower lobe |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed posterior left lower lobe on side |
Exam Action 03/29/22 2:05 AM MDT |
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Percussed posterior left lower lobe near spine |
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