Focused Exam: Cough Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Your Results Lab Pass
Overview Transcri
Transcript
pt
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
Documentation 06/04/18 2:50 PM
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]
1/21
,6/4/2018
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, though. It's just clear.
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 Question
cough?.) 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
2/21
, 6/4/2018
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 how they smell.
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 breathe it a little bit then, but it's not all the time or anything. I
don't like how it smells.
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 breathe it a little bit then, but it's not all the time or anything. I
don't like how it smells.
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 Educate
sure you're around no one that is smoking 06/04/18 3:03 PM
CDT
Oh, OK.
3/21
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