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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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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

Return to Assignment

Your Results

Reopen
Lab Pass

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

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

83 minutes

total spent in assignment

Interaction with patient

83 minutes

Transcript

Started:
Mar 29, 2022
|
Total Time:
83 min

All Lines (122)
Interview Questions (79)
Statements (7)
Exam Actions (36)

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

Hi.

what is your name

Question

03/29/22 12:04 AM MDT

My name is Daniel Rivera, but I just go by Danny.

Hi Danny, how old are you? (Clarified to Hi, how are you?.)

Question

03/29/22 12:04 AM MDT

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.)

I am sorry that you not feeling well

Empathize

03/29/22 12:05 AM MDT

Thank you.

how old are you

Question

03/29/22 12:05 AM MDT

I’m eight.

when is you birth date

Question

03/29/22 12:05 AM MDT

I was born March 4th in, um . . . [Danny reports correct birth year.]

tell me what brings you in today

Question

03/29/22 12:06 AM MDT

My Abuela brought me here because I’ve been feeling sick. I have been coughing a lot. . . and I feel kinda tired.

Do you have cough?

Question

03/29/22 12:06 AM MDT

I guess I’m kind of sick. . . I’ve been coughing a lot.

when did the cough starts

Question

03/29/22 12:07 AM MDT

I think the cough started four. . . No, it started five days ago.

how long have you had cough

Question

03/29/22 12:07 AM MDT

I think the cough started four. . . No, it started five days ago.

tell me about how your cough is

Question

03/29/22 12:08 AM MDT

I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.

is your cough wet

Question

03/29/22 12:08 AM MDT

Yeah . . . my cough seems kind of gurgly and watery.

how frequent do you cough

Question

03/29/22 12:08 AM MDT

I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.

how long do your cough last

Question

03/29/22 12:09 AM MDT

I think the cough started four. . . No, it started five days ago.

what makes your cough worse

Question

03/29/22 12:09 AM MDT

My cough mostly stays the same no matter what I do. It seems to get worse at night though.

is the cough worse at night?

Question

03/29/22 12:10 AM MDT

Yeah, my cough’s worse at night.

does your cough wakes you at night

Question

03/29/22 12:10 AM MDT

I can’t fall asleep much because I keep coughing.

do you smoke

Question

03/29/22 12:11 AM MDT

No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell.

are you ever around cigarette smoke

Question

03/29/22 12:12 AM MDT

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.

have you done anything to treat your cough?

Question

03/29/22 12:12 AM MDT

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

what name was the cough medicine

Question

03/29/22 12:13 AM MDT

I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON]

what color was the cough medicine

Question

03/29/22 12:14 AM MDT

Um, it was purple-ish. It tasted gross.

how much cough medicine did you take

Question

03/29/22 12:14 AM MDT

I just had one spoonful of it.

who gave you the cough medication

Question

03/29/22 12:15 AM MDT

My mom.

how many times have you taken the cough syrup

Question

03/29/22 12:15 AM MDT

I only took the cough medicine once. My mom gave me a spoonful. [AUDIO COMING SOON]

did it help with the cough (No matching questions found.)

Question

03/29/22 12:16 AM MDT

did it help with the cough (No matching questions found.)

Question

03/29/22 12:17 AM MDT

did it help with the cough (No matching questions found.)

Question

03/29/22 12:17 AM MDT

have you try any home remedies for your cough

Question

03/29/22 12:18 AM MDT

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

do you take any medications from a doctor

Question

03/29/22 12:18 AM MDT

No. [AUDIO COMING SOON]

do you take any vitamins

Question

03/29/22 12:18 AM MDT

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!

taking too much vitamins can cause other health issues

Educate

03/29/22 12:19 AM MDT

Oh, OK.

what other OTC do you take

Question

03/29/22 12:20 AM MDT

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.

are you active most of the time

Question

03/29/22 12:20 AM MDT

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]

have you been less active since you been sick (No matching questions found.)

Question

03/29/22 12:21 AM MDT

have you been less active since you been sick (No matching questions found.)

Question

03/29/22 12:21 AM MDT

are you less active now

Question

03/29/22 12:22 AM MDT

No, I don’t feel nauseous.

has your activity changed since you been sick

Question

03/29/22 12:22 AM MDT

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]

are you able to keep up when you play with your classmates (No matching questions found.)

Question

03/29/22 12:23 AM MDT

are you able to focus

Question

03/29/22 12:23 AM MDT

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]

do you have runny nose

Question

03/29/22 12:24 AM MDT

My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.

have you been sneezing

Question

03/29/22 12:25 AM MDT

I don’t usually have to sneeze. My nose gets runny a lot of times though, like I have a cold.

what color is your snot

Question

03/29/22 12:25 AM MDT

You mean like when I blow my nose? It’s clear.

what is the consistency of your nasal drainage

Question

03/29/22 12:26 AM MDT

It’s kind of clear and, like, watery.

do you have any ear infection

Question

03/29/22 12:27 AM MDT

I don’t know if it is infected, but my right ear kind of hurts.

sorry to hear that

Empathize

03/29/22 12:27 AM MDT

Thank you.

do you have any drainage from your ears

Question

03/29/22 12:27 AM MDT

No, nothing comes out of my ears, but my right ear kind of hurts.

do you have any hearing problems

Question

03/29/22 12:28 AM MDT

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 . . .

do you have any sore throat

Question

03/29/22 12:29 AM MDT

It feels a little bit sore, yeah.

does it hurts when you swallow

Question

03/29/22 12:29 AM MDT

No, I can swallow OK. It hurts a little right now because my throat is kinda sore.

do you get runny nose often

Question

03/29/22 12:31 AM MDT

My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.

do you have coughs often (Clarified to Are you coughing a lot?.)

Question

03/29/22 12:32 AM MDT

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.)

have you had pneumonia

Question

03/29/22 12:32 AM MDT

I think I had that last year, when I was seven. My mom was really worried.

how did it get treated (No matching questions found.)

Question

03/29/22 12:33 AM MDT

do you have asthma

Question

03/29/22 12:33 AM MDT

Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don’t have to.

do you have asthma

Question

03/29/22 12:33 AM MDT

Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don’t have to.

are you up to date on your immunizations?

Question

03/29/22 12:34 AM MDT

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.

shots are good to protect you from illness

Educate

03/29/22 12:35 AM MDT

Oh, OK.

do you have seasonal allergies

Question

03/29/22 12:35 AM MDT

I don’t think I have any allergies like that.

do you have allergies to any medication

Question

03/29/22 12:38 AM MDT

I don’t think I’m allergic to medicine.

any allergies to food

Question

03/29/22 12:38 AM MDT

I’m not allergic to any foods I don’t think.

any family history of allergies

Question

03/29/22 12:38 AM MDT

I don’t think so, but I guess I’m not sure.

any family history of asthma

Question

03/29/22 12:39 AM MDT

Only Papi had asthma, I think.

do you have fever

Question

03/29/22 12:39 AM MDT

My mom said I didn’t have a fever this morning before Abuela took me here.

do you have any chills

Question

03/29/22 12:40 AM MDT

No, I haven’t felt that.

do you have fatigue

Question

03/29/22 12:40 AM MDT

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.

sorry to hear that

Empathize

03/29/22 12:40 AM MDT

Thank you.

do you have night sweats

Question

03/29/22 12:41 AM MDT

I don’t sweat at night unless it gets really hot or something.

have you been sleeping okay

Question

03/29/22 12:41 AM MDT

Most times I sleep OK, but I haven’t been able to sleep much because of my cough.

do you notice any swelling

Question

03/29/22 12:41 AM MDT

Nothing’s swollen.

do you get frequent colds

Question

03/29/22 12:42 AM MDT

I get colds a lot. My nose is always runny.

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

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.)

do you have headaches

Question

03/29/22 12:43 AM MDT

I don’t usually get headaches.

do you get nose bleeds

Question

03/29/22 12:43 AM MDT

Just one time. Tony and I were kicking a ball at recess and I got hit in the nose.

sorry about that

Empathize

03/29/22 12:44 AM MDT

Thank you.

do you have any vision problems

Question

03/29/22 12:44 AM MDT

No, I see really good. Oh, I mean, I see well. I think glasses are kind of cool though. My friend Tony has them.

do you get dizzy

Question

03/29/22 12:45 AM MDT

I only get dizzy if I’m spinning around a lot at recess.

do you have any sinus pain

Question

03/29/22 12:45 AM MDT

It doesn’t hurt there.

do you have chest pain

Question

03/29/22 12:45 AM MDT

No, I don’t have pain in my chest. I would hate that!

do you have any shortness of breath

Question

03/29/22 12:46 AM MDT

My breathing seems good. My nose is kind of runny right now, but I can still breathe OK.

do you have any siblings

Question

03/29/22 12:46 AM MDT

No, I’m the only kid in my house.

does your friend Tony gets runny nose too (Clarified to Is tony sick?.)

Question

03/29/22 12:47 AM MDT

None of my friends are sick that I know of. (Clarified to if Tony is sick.)

Checked vitals

Exam Action

03/29/22 12:48 AM MDT

Inspected right orbital area and sclera

Exam Action

03/29/22 12:49 AM MDT

Inspected upper conjunctiva

Exam Action

03/29/22 12:49 AM MDT

Inspected upper conjunctiva

Exam Action

03/29/22 12:49 AM MDT

Inspected right orbital area and sclera

Exam Action

03/29/22 12:49 AM MDT

Inspected left orbital area and sclera

Exam Action

03/29/22 12:49 AM MDT

Inspected lower conjunctiva

Exam Action

03/29/22 12:50 AM MDT

Performed otoscopic examination of right naris

Exam Action

03/29/22 12:50 AM MDT

Performed otoscopic examination of left naris

Exam Action

03/29/22 12:51 AM MDT

Performed otoscopic examination of right ear

Exam Action

03/29/22 12:52 AM MDT

Performed otoscopic examination of left ear

Exam Action

03/29/22 12:52 AM MDT

Inspected mouth

Exam Action

03/29/22 12:53 AM MDT

Inspected front of neck

Exam Action

03/29/22 12:54 AM MDT

Inspected right side of neck

Exam Action

03/29/22 12:54 AM MDT

Inspected back of neck

Exam Action

03/29/22 12:54 AM MDT

Inspected right side of neck

Exam Action

03/29/22 12:55 AM MDT

Inspected front of neck

Exam Action

03/29/22 12:55 AM MDT

Inspected anterior chest wall

Exam Action

03/29/22 12:55 AM MDT

Inspected posterior chest wall

Exam Action

03/29/22 12:55 AM MDT

does resting help your cough

Question

03/29/22 1:57 AM MDT

My cough has just stayed the same. I’ve taken some naps, but it doesn’t seem to help.

does drinking water helps your cough

Question

03/29/22 1:58 AM MDT

Drinking water doesn’t do anything to my cough.

how long have had ear pain

Question

03/29/22 2:00 AM MDT

My right ear just started hurting yesterday. I think it’s because I’m sick.

Thanks for telling what you know about you and family history. That was a great job

Question

03/29/22 2:02 AM MDT

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.

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

Thank you.

Percussed anterior right upper lobe

Exam Action

03/29/22 2:05 AM MDT

Percussed anterior left upper lobe

Exam Action

03/29/22 2:05 AM MDT

Percussed anterior right middle lobe

Exam Action

03/29/22 2:05 AM MDT

Percussed anterior left mid-chest (upper lobe)

Exam Action

03/29/22 2:05 AM MDT

Percussed anterior right lower lobe

Exam Action

03/29/22 2:05 AM MDT

Percussed anterior left lower lobe

Exam Action

03/29/22 2:05 AM MDT

Percussed posterior left upper lobe

Exam Action

03/29/22 2:05 AM MDT

Percussed posterior right upper lobe

Exam Action

03/29/22 2:05 AM MDT

Percussed posterior left mid-back (lower lobe)

Exam Action

03/29/22 2:05 AM MDT

Percussed posterior right mid-back (lower lobe)

Exam Action

03/29/22 2:05 AM MDT

Percussed posterior left lower lobe

Exam Action

03/29/22 2:05 AM MDT

Percussed posterior right lower lobe

Exam Action

03/29/22 2:05 AM MDT

Percussed posterior left lower lobe on side

Exam Action

03/29/22 2:05 AM MDT

Percussed posterior left lower lobe near spine

Exam Action

03/29/22