NR 509 Shadow Health Focused Exam Case: Cough MODIFIED
Focused Exam: Cough Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Your Lab Pass
Results
Transcript
Overview
Transcript
Started: Jun 04, 2018 | Patient Exam Time: 86 min
Subjective Data
All Lines (180) Interview Questions (76) Statements (8) Exam Actions (96)
Collection Objective
Greet
Data Collection Hello, My name is Sara an FNP student and I will be
06/04/18 2:50 PM
interviewing you today
CDT
Education & Empathy
Documentation
Hi.
Self-Reflection
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 06/04/18 2:52 PM
birth? CDT
I was born March 4th in, um . . . [Danny reports correct
1/21
,birth year.] [AUDIO COMING SOON]
2/21
, 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 strang
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 n
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 cough?.)
Question
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
3/21
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