NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

• 
  

  Finding:

  Established chief complaint

• 
  

  Finding:

  Reports cough

  (Found)

  Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

  Example Question:

  Do you have a cough?

• 
  

  Finding:

  Asked about onset of cough

• 
  

  Finding:

  Reports cough started 5 days ago

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  How long have you had a cough?

• 
  

  Finding:

  Asked about frequency and duration of cough

• 
  

  Finding:

  Reports coughing every few minutes

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

  Example Question:

  How frequently have you been coughing?

• 
  

  Finding:

  Asked about character of cough

• 
  

  Finding:

  Reports cough is wet

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Is your cough a wet cough?
• 
  

  Finding:

  Reports clear sputum

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you produce any phlegm or sputum with your cough?

• 
  

  Finding:

  Asked about aggravating factors for cough

• 
  

  Finding:

  Reports cough is worse at night

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Is your cough worse at night?
• 
  

  Finding:

  Reports exposure to secondhand smoke

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Are you around anyone who smokes at home?
• 
  

  Finding:

  Denies knowing what makes the cough worse

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  What makes your cough worse?

• 
  

  Finding:

  Asked about relieving factors for cough

• 
  

  Finding:

  Denies resting relieves cough

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Does resting help your cough?
• 
  

  Finding:

  Denies drinking water relieves cough

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

  Example Question:

  Does drinking water help your cough?

• 
  

  Finding:

  Asked about nasal symptoms

• 
  

  Finding:

  Reports current runny nose

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you have a runny nose?
• 
  

  Finding:

  Denies sneezing

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Have you been sneezing?
• 
  

  Finding:

  Reports frequent runny nose

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you get runny noses often?

• 
  

  Finding:

  Followed up on nasal discharge

• 
  

  Finding:

  Reports nasal discharge is clear

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  What color is your snot?
• 
  

  Finding:

  Reports nasal discharge is thin

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

  Example Question:

  Is your snot thin?

• 
  

  Finding:

  Asked about ear symptoms

• 
  

  Finding:

  Reports pain in right ear

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you have any ear pain?

• 
  

  Finding:

  Followed up on ear pain

• 
  

  Finding:

  Reports ear pain started yesterday

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  How long have you had ear pain?
• 
  

  Finding:

  Reports ear pain is a 3 out of 10

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Can you rate your ear pain on a scale?
• 
  

  Finding:

  Denies ear discharge

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you have any ear discharge?

• 
  

  Finding:

  Asked about throat symptoms

• 
  

  Finding:

  Reports sore throat

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

  Example Question:

  Is your throat sore?
• 
  

  Finding:

  Reports “a little” pain with swallowing

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Does it hurt when you swallow?

• 
  

  Finding:

  Asked about allergies

• 
  

  Finding:

  Denies seasonal allergies

  (Available)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you have seasonal allergies?
• 
  

  Finding:

  Denies food allergies

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Do you have food allergies?
• 
  

  Finding:

  Denies medication allergies

  (Available)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Are you allergic to any medicine?
• 
  

  Finding:

  Denies allergies to animals

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Are you allergic to animals?
• NURS6512 Week 5 – Focused Exam: Cough Danny Rivera
  

  Finding:

  Denies latex allergy

  (Available)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

  Example Question:

  Are you allergic to latex?

• 
  

  Finding:

  Asked about contact with illnesses

• 
  

  Finding:

  Denies being around anyone ill at home

  (Found)

  Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

  Example Question:

  Is anyone sick at home?

• 
  

  Finding:

  Asked about home medications

• 
  

  Finding:

  Confirmed home medications

  (Found)

  Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

  Example Question:

  What medications do you take?
• 
  

  Finding:

  Reports taking a daily vitamin

  (Found)

  Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

  Example Question:

  Do you take vitamins?
• 
  

  Finding:

  Reports taking cough medicine

  (Found)

  Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

  Example Question:

  Are you taking medication for your cough?

• 
  

  Finding:

  Followed up on cough medicine

• 
  

  Finding:

  Reports cough medicine was purple

  (Found)

  Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

  Example Question:

  What color was the cough medicine?
• 
  

  Finding:

  Reports taking one spoonful of cough medicine

  (Found)

  Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

  Example Question:

  How much cough medicine did you take?
• 
  

  Finding:

  Reports mother gave him the medicine

  (Found)

  Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

  Example Question:

  Who gave you the cough medicine?
• 
  

  Finding:

  Reports cough medicine provided temporary relief

  (Found)

  Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

  Example Question:

  Did the cough medicine make you feel better?

• 
  

  Finding:

  Asked about relevant medical history

• 
  

  Finding:

  Denies asthma diagnosis

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

  Example Question:

  Do you have asthma?
• 
  

  Finding:

  Reports immunizations as current

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Do you have current immunizations?
• 
  

  Finding:

  Reports past pneumonia and frequent coughs

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Do you have a history of respiratory problems?
• 
  

  Finding:

  Denies past hospitalizations

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Have you ever been to the hospital?

• 
  

  Finding:

  Asked about exposure to secondhand smoke

• 
  

  Finding:

  Reports father smokes cigars

  (Found)

  Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

  Example Question:

  Who smokes at home?
• 
  

  Finding:

  Reports father sometimes forgets to take cigars outside

  (Found)

  Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

  Example Question:

  Where does your father smoke?

• 
  

  Finding:

  Asked about living conditions

• 
  

  Finding:

  Reports living in a house with parents and grandparents

  (Available)

  Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

  Example Question:

  Where do you live?
• 
  

  Finding:

  Reports feeling safe at home

  (Available)

  Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

  Example Question:

  Do you feel safe at home?
• 
  

  Finding:

  Reports park with playground near home

  (Found)

  Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives.

  Example Question:

  Is there anywhere near your home where you can play outside?

• 
  

  Finding:

  Asked about constitutional health

• 
  

  Finding:

  Denies fever

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have a fever?
• 
  

  Finding:

  Denies chills

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have chills?
• 
  

  Finding:

  Reports feeling “kind of tired”

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have fatigue?
• 
  

  Finding:

  Denies night sweats

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have night sweats?
• 
  

  Finding:

  Denies weight loss

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Has your weight changed?
• 
  

  Finding:

  Denies appetite loss

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Have you lost your appetite?

• 
  

  Finding:

  Asked about review of systems for HEENT

• 
  

  Finding:

  Denies ear popping or crackling

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you hear any popping sounds?
• 
  

  Finding:

  Reports history of frequent ear infections

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Have you ever had ear infections?
• 
  

  Finding:

  Denies ear surgery or ear tubes

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Have you ever had surgery on your ears?
• 
  

  Finding:

  Denies headaches

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you get headaches?
• 
  

  Finding:

  Denies nosebleeds

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have nosebleeds?
• 
  

  Finding:

  Denies vision problems

  (Available)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any problems with your vision?
• 
  

  Finding:

  Denies dizziness

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

  Example Question:

  Do you have any dizziness?
• 
  

  Finding:

  Denies watery eyes

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have watery eyes?
• 
  

  Finding:

  Denies eye redness

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have eye redness?
• 
  

  Finding:

  Denies eye pain

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any eye pain?
• 
  

  Finding:

  Denies sinus pain

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any sinus pain?
• 
  

  Finding:

  Denies hearing problems

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any hearing problems?

• 
  

  Finding:

  Asked about review of systems for respiratory

• 
  

  Finding:

  Denies difficulty breathing

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have difficulty breathing?
• 
  

  Finding:

  Denies chest tightness

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have chest tightness?
• 
  

  Finding:

  Denies chest pain

  (Found)

  Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.

  Example Question:

  Do you have any chest pain?
• 
  

  Finding:

  Denies history of inhaler use or breathing treatments

Objective Data Collection: 11.27 of 13 (86.69%) – NURS6512 Week 5 – Focused Exam: Cough Danny Rivera

•  Correct
•  Partially correct

•  Incorrect
•  Missed

 Inspected eyes and orbital area 1 of 1 point

 

Orbital Area (1/4 point)

•  No visible abnormal findings
•  Ptosis
•  Eyelid edema
•  Lesion
•  Allergic shiners

Sclera (1/4 point)

•  White
•  Jaundice
•  Injection
•  Icterus

Conjunctiva (1/4 point)

•  Moist and pink
•  Pale
•  Dry appearance
•  Erythema
•  Edema

Conjunctival Discharge (1/4 point)

•  No discharge
•  Clear, watery discharge
•  Purulent discharge

 Inspected nasal cavities 1 of 1 point

 

Color (1/4 point)

•  Pink
•  Erythemic
•  Bluish

Discharge (1/4 point)

•  No discharge
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

Turbinate Patency (1/4 point)

•  Patent
•  Decreased patency
•  Not patent

Observations (1/4 point)

•  No additional visible abnormal findings
•  Foreign body present
•  Polyp
•  Septum perforated
•  Septum deviated
•  Lesion

 Inspected ears 0.8 of 1 point

 

Right: Auditory Canal Color (No point)

•  Pink
•  Erythemic
•  Pallor

Right: Tympanic Membrane Color (No point)

•  Pearly gray
•  Erythemic
•  Opaque
•  Yellow
•  Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 point)

•  No visible abnormal findings
•  Fluid observed
•  Visible scars
•  Bulging
•  Perforation
•  Retraction

Right: Cone Of Light (1/10 point)

•  5:00
•  Cone of light distorted

Right: Discharge (1/10 point)

•  No discharge
•  Cerumen
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

Left: Auditory Canal Color (1/10 point)

•  Pink
•  Erythemic
•  Pallor

Left: Tympanic Membrane Color (1/10 point)

•  Pearly gray
•  Erythemic
•  Opaque
•  Yellow
•  Not visible because of cerumen

Left: Tympanic Membrane Appearance (1/10 point)

•  No visible abnormal findings
•  Fluid observed
•  Visible scars
•  Bulging
•  Perforation
•  Retraction

Left: Cone Of Light (1/10 point)

•  7:00
•  Cone of light distorted

Left: Discharge (1/10 point)

•  No discharge
•  Cerumen
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

 Inspected mouth and throat 0.8 of 1 point

 

Oral Mucosa (No point)

•  Moist and pink
•  Dry appearance
•  Erythema

Tonsils (1/5 point)

•  No visible abnormal findings
•  Edema
•  Erythema

Posterior Oropharynx Color (1/5 point)

•  Pink
•  Erythemic

Posterior Oropharynx Texture (1/5 point)

•  No abnormal findings
•  Cobblestoning
•  Exudate

Post Nasal Drip (1/5 point)

•  No discharge
•  Clear discharge
•  Purulent discharge

 Inspected neck  1 of 1 point

 

Symmetry (1/2 point)

•  Symmetric
•  Asymmetric

Appearance (1/2 point)

•  No visible abnormal findings
•  Swelling
•  Visible pulsation
•  Visible mass
•  Discoloration

 Inspected chest 1 of 1 point

 

Symmetry (1/2 point)

•  Symmetric
•  Asymmetric

Appearance (1/2 point)

•  No visible abnormal findings
•  Rash or lesion
•  AP diameter abnormal Intercostal retraction while breathing
•  Excessive use of accessory muscles while breathing
•  Pectus excavatum
•  Skin growths (freckles or moles)
•  Evidence of skin trauma (scar, laceration, or bruising)

 Palpated sinuses 1 of 1 point

 

Frontal (1/2 point)

•  None reported
•  Tenderness reported

Maxillary (1/2 point)

•  None reported
•  Tenderness reported

 Palpated lymph nodes 0.67 of 1 point

 

Cervical (No point)

•  No palpable nodes
•  Palpable nodes on right side
•  Palpable nodes on left side

Supraclavicular (1/3 point)

•  No palpable nodes
•  Palpable nodes on right side
•  Palpable nodes on left side

Axillary (1/3 point)

•  No palpable nodes
•  Palpable nodes on right side
•  Palpable nodes on left side

 Palpated fremitus 1 of 1 point

 

Symmetry (1/2 point)

•  Equal bilaterally
•  Unequal bilaterally

Vibration (1/2 point)

•  Expected fremitus
•  Decreased fremitus

 Auscultated breath sounds 1 of 1 point

 

Breath Sounds (1/3 point)

•  Present in all areas
•  Diminished in some areas
•  Absent in some areas

Adventitious Sounds (1/3 point)

•  No adventitious sounds
•  Wheezing
•  Fine crackles
•  Stridor
•  Rhonchi
•  Rales

Location (1/3 point)

•  All areas clear
•  Adventitious sounds in anterior right upper lobe
•  Adventitious sounds in anterior right middle lobe
•  Adventitious sounds in anterior right lower lobe
•  Adventitious sounds in anterior left upper lobe
•  Adventitious sounds in anterior left lower lobe
•  Adventitious sounds in posterior right upper lobe
•  Adventitious sounds in posterior right lower lobe
•  Adventitious sounds in posterior left upper lobe
•  Adventitious sounds in posterior left lower lobe

 Auscultated for bronchophony 0 of 1 point

Bronchophony (No point)

•  Positive
•  Negative

 Auscultated heart sounds

 

Heart Sounds (1/2 point)

•  S1 and S2 audible
•  S1, S2, and S3 audible
•  S1, S2, and S4 audible
•  S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

•  No extra sounds
•  Gallops
•  Murmur
•  Friction rub
•  Valve clicks

 Percussed chest wall 1 of 1 point

 

Observations (1/2 point)

•  All areas resonant
•  Some areas dull, some resonant
•  Some areas hyperresonant, some resonant

Location (1/2 point)

•  No areas of dullness
•  Dullness, anterior right upper lobe
•  Dullness, anterior right middle lobe
•  Dullness, anterior right lower lobe
•  Dullness, anterior left upper lobe
•  Dullness, anterior left lower lobe
•  Dullness, posterior right upper lobe
•  Dullness, posterior right lower lobe
•  Dullness, posterior left upper lobe
•  Dullness, posterior left lower lobe

Education & Empathy : 3 of 5 (60.0%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

• Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
• Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
• Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

 1 Symptoms Followed Up

	Description: Danny describes the symptoms that have been bothering him.
	How are you doing today ?	Question 12:38 PM MDT
	I don’t feel so good. I keep coughing and I feel a little bit tired.
	Oh, I’m sorry to hear that Danny	Empathize 12:39 PM MDT
	Thank you.
	How was your pain in your throat feels like ?	Question 01:44 PM MDT
	Um, it just feels kind of sore. I can feel it a little bit when I swallow.
	Oh, I am sorry to hear that Danny.	Empathize 01:46 PM MDT
	Thank you.
	Do you have a pain now ? (Clarified to: Do you have pain right now?)	Question 05:27 PM MDT
	The only thing that really hurts is my right ear, but it just hurts a little bit. It just started . . . I’m not sure what will make it feel better. (Clarified to: if I am in pain right now)
	I’m sorry to hear that	Empathize 05:27 PM MDT
	Thank you.
	How often do you said you are coughing ?	Question 05:27 PM MDT
	I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera
	I’m sorry it must be really uncomfortable.	Empathize 05:28 PM MDT
	Thank you.
	Model Statement: “I’m sorry your ear and your throat hurt. I’ll take a look and we’ll see if we can help you feel better.”

 2 Medications Not Followed Up

 

	Description: Danny describes the medication he was given for his cough.
	What helps you cough ?	Question 01:01 PM MDT
	I had some cough medicine this morning. [AUDIO COMING SOON]
	Resting helps you ? (Clarified to: Does rest relieve your cough?)	Question 01:03 PM MDT
	My cough has just stayed the same. I’ve taken some naps, but it doesn’t seem to help. (Clarified to: if rest relieves my cough)
	Does drinking water helps your cough ?	Question 01:03 PM MDT
	Drinking water doesn’t do anything to my cough.
	Model Statement: “Thanks for telling me what you know about the medications you take. I can ask your mom or your abuela for more information.”

 3 Vitamins Followed Up

 

	Description: Danny describes taking vitamins.
	You take vitamins ? (Clarified to: Do you take a multivitamin every day?)	Question 01:12 PM 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! (Clarified to: if I take a vitamin every day)
	It’s not good to take the extra one because it is important medication or vitamins dosages and the excess amount may hurt you.	Educate 01:14 PM MDT
	Oh, OK.
	Model Statement: “You’re right; taking vitamins can be good for you. However, sometimes taking too many vitamins can be bad for you. It’d be better if you don’t sneak extra vitamins — just take the amount that your mom gives you.”

 4 Secondhand Smoke Followed Up

 

	Description: Danny describes exposure to secondhand smoke at home.
	Do you smoke ?	Question 12:52 PM MDT
	No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell.
	Is Papi smokes at home around you ?	Question 12:54 PM MDT
	Yeah, sometimes Papi smokes cigars inside. He forgets to take them outside and my mom has to remind him. [AUDIO COMING SOON]
	It’s called secondary smoke When someone at home smokes they need to go to outside. Please dont be around the people who smoking. It is called secondary smoke. If you see somebody smoking and have no intentions to leave or you coming to the place where somebody smoked please do not stay in the same area. You need to leave. It is called secondary smoking and may affect your lungs when you inhale the smoke.	Educate 01:00 PM MDT
	Oh, OK.
	Model Statement: “That’s too bad your Papi smokes cigars at home. It sounds like it bothers you. Breathing in smoke isn’t very healthy, so it’s good to stay out rooms where you can smell cigar smoke.”

 5 Family History Not Followed Up

 

	Description: Danny describes what he knows about his family health history.
	Is anybody sick in your house ?	Question 01:28 PM MDT
	Nobody at home is sick I don’t think.
	Do you have any family history of asthma ?	Question 01:28 PM MDT
	Mom says Papi had asthma when he was a little kid.
	Anybody in your family has allergies ?	Question 01:28 PM MDT
	I don’t think so, but I guess I’m not sure.
	Do you have any pets at home ?	Question 01:29 PM MDT
	No, but I keep asking my mom if I can get a lizard.NURS6512 Week 5 – Focused Exam: Cough Danny Rivera
	What do you do when you have a free time ?	Question 01:30 PM MDT
	Usually I play video games or read or try to write stories. If Tony is here, we do that stuff together.
	Model Statement: “Thanks for telling me what you know about your family history. You did a good job remembering.”

 

Documentation / Electronic Health Record

• Document: Vitals
• Document: Provider Notes

Document: Vitals

Vitals
Blood Pressure	120/76
O2 Sat	96
Pulse	100
Resp. Rate	28
Temperature	37.2

 

Pediatric Cough Shadow Health For Danny Rivera

10–13 minutes

---

Student Documentation	Model Documentation
Subjective Danny Rivera is an 8 year old male patient who reports to have had a cough for the last 4 to 5 days. He reports the cough is worse at night and makes him not sleep well and also gets fatigued. He describes the cough as watery. He also has a running nose. He has mild soreness in his throat which he relieves with over the counter drugs. He had ear infections when young and had pneumonia in the past. He denies any headache, dizziness, fever, sputum, chest pain, , abdominal pain or breathing problems. His cough does not get worse when he is active.	Return to Canvas to complete your SOAP note for this assignment. Pediatric Cough Shadow Health for Danny Rivera
Objective HEET: Mucus membranes are moist, with a clear nasal discharge. Redness, cobblestoning at the back of the throat. Eyes are dull with pink conjuctiva. Right tympanic memebrane is inflamed . It is also red. The right cervical lymph node is tender and enlarged. Cardiovasicular: S1, S2. There is neither murmurs, gallops nor rubs. Respiratory: Respiratory rate is increased but no distress. Breath sounds are clear to auscultation and negative bronchophony. The chest wall is resonant to percusion. Spirom… Pediatric Cough Shadow Health for Danny Rivera

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Week 4: SBAR Focused Exam: Cough Results | Turned In – Pediatric Cough Shadow Health for Danny Rivera

NUR 3069C Health Assessment and Communication – May ’18 (Gannon – Jacksonville Only), 3069C

Return to Assignment

Your Results

Lab Pass

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Experience Overview

Patient: Danny Rivera

Student Performance Index

32.95 out of 34

Documentation

SBAR

Proficiency Level: Proficient

Digital Clinical Experience Score – Pediatric Cough Shadow Health for Danny Rivera

96.9%

• Beginning
• Developing
• Proficient

Students rated as “proficient” demonstrate entry-level expertise in nursing competencies and clinical reasoning skills. In comparable nursing programs, the top 25% of students perform at the level of a proficient nurse.

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

Subjective Data Collection

19 out of 19

Time

Objective Data Collection

13.95 out of 15

documentation or time spent.

72 minutes total spent in assignment

Interaction with patient

72 minutes

Objective Data Collection: 13.95 of 15 (93%) Pediatric Cough Shadow Health for Danny Rivera

• Correct
• Partially correct
• Incorrect
• Missed

Inspected eyes and orbital area                                1of1point

Orbital Area (1/4 point)

Sclera (1/4 point)

• No visible abnormal findings Ptosis
• Eyelid Lesion
• White Yellow tint Redness

Conjunctiva (1/4 point)

Conjunctival Discharge (1/4 point)

• Moist and pink Dry appearance Redness Swelling
• No discharge
• Clear, watery discharge Purulent discharge

Inspected nasal cavities                            0.75of1point

Color (No point)

Discharge (1/4 point)

• Pink Red Bluish
• No discharge Clear discharge Bloody discharge Purulent discharge

Turbinate Patency (1/4 point)

Observations (1/4 point)

• Patent
• Decreased patency Not patent
• No additional visible abnormal findings Foreign body present
• Polyp
• Septum perforated Septum deviated Lesion

Inspected ears                              0.8of1point

Right: Auditory Canal Color (No point)

Right: Tympanic Membrane Color (No point) Pediatric Cough Shadow Health for Danny Rivera

• Pink Red Pallor
• Pearly gray Red Opaque Yellow
• Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 point)

• No visible abnormal findings Fluid observed
• Visible scars Bulging
• Perforation
• Retraction

Right: Cone Of Light (1/10 point)

5:00

• Cone of light distorted

Right: Discharge (1/10 point)

Left: Auditory Canal Color (1/10 point)

• No discharge Cerumen
• Clear discharge Bloody discharge Purulent discharge
• Pink Red Pallor

Left: Tympanic Membrane Color (1/10 point)

Left: Tympanic Membrane Appearance (1/10 point)

• Pearly gray Red Opaque Yellow
• Not visible because of cerumen
• No visible abnormal findings Fluid observed
• Visible scars Bulging Perforation Retraction

Left: Cone Of Light (1/10 point)

Left: Discharge (1/10 point)

7:00

• Cone of light distorted
• No discharge Cerumen
• Clear discharge Bloody discharge Purulent discharge

Inspected mouth and throat                              0.4of1point

Oral Mucosa (No point)

Tonsils (No point) Pediatric Cough Shadow Health for Danny Rivera

• Moist and pink Dry appearance Redness
• No visible abnormal findings Swelling
• Redness

Throat Color (1/5 point)

Throat Texture (1/5 point)

• Pink Red
• No abnormal findings Cobblestoning Exudate

Post Nasal Drip (No point)

• No discharge
• Clear discharge
• Purulent discharge

Inspected neck                                1of1 point

Symmetry (1/2 point)

Appearance (1/2 point)

• Symmetric Asymmetric
• No visible abnormal findings Swelling
• Visible pulsation Visible mass Discoloration

Inspected chest                                1of1 point

Symmetry (1/2 point)

Appearance (1/2 point)

• Symmetric Asymmetric
• No visible abnormal findings Rash
• Barrel chest
• Intercostal retraction while breathing Excessive use of accessory muscles while
• breathing
• Skin growths (freckles or moles)

Auscultated breath sounds                                1of1point

Breath Sounds (1/3 point)

Adventitious Sounds (1/3 point)

• Present in all areas Diminished in some areas Absent in some areas
• No adventitious sounds Wheezing
• Fine crackles Stridor Rhonchi Rales

Location (1/3 point) Pediatric Cough Shadow Health for Danny Rivera

All areas clear

• Adventitious sounds in anterior right upper lobe Adventitious sounds in anterior right middle lobe
• Adventitious sounds in anterior right lower lobe Adventitious sounds in anterior left upper lobe
• Adventitious sounds in anterior left lower lobe Adventitious sounds in posterior right upper lobe
• Adventitious sounds in posterior right lower lobe Adventitious sounds in posterior left upper lobe
• Adventitious sounds in posterior left lower lobe

Auscultated for bronchophony                                1of1point

Bronchophony (1/1 point)

• Positive
• Negative

Auscultated heart sounds                                1of1point

Heart Sounds (1/2 point)

Extra Heart Sounds (1/2 point)

• S1 and S2 audible
• S1, S2, and S3 audible S1, S2, and S4 audible
• S1, S2, S3, and S4 audible
• No extra sounds Gallops
• Murmur Friction rub Valve clicks

Percussed chest wall                                1of1point

Observations (1/2 point)

Location (1/2 point)

• All areas resonant
• Some areas dull, some resonant
• Some areas hyperresonant, some resonant
• No areas of dullness

Dullness

• anterior right upper lobe Dullness
• anterior right middle lobe Dullness
• anterior right lower lobe Dullness
• anterior left upper lobe Dullness
• anterior left lower lobe Dullness
• posterior right upper lobe Dullness
• posterior right lower lobe Dullness
• posterior left upper lobe Dullness
• posterior left lower lobe Pediatric Cough Shadow Health for Danny Rivera

Measured diaphragmatic excursion                                1of1point

Range (1/1 point) Pediatric Cough Shadow Health for Danny Rivera

• 3-5 cm
• Greater than 3-5 cm
• Less than 3-5 cm

Palpated sinuses                                1of1point

Frontal (1/2 point)

Maxillary (1/2 point)

• None reported Tenderness reported
• None reported Tenderness reported

Palpated lymph nodes                                1of1point

Head And Neck (1/3 point)

Supraclavicular (1/3 point)

• No palpabe nodes
• Palpable nodes on right side
• Palpable nodes on left side
• No palpable nodes

Axillary (1/3 point) Pediatric Cough Shadow Health for Danny Rivera

• No palpable nodes
• Palpable nodes on right side
• Palpable nodes on left side

Palpated fremitus                                1of1point

Symmetry (1/2 point)

Vibration (1/2 point

• Equal bilaterally
• Unequal bilaterally
• Expected fremitus
• Decreased fremitus

alpated chest expansion                                                                               1 of 1 point

Symmetry (1/1 point) Pediatric Cough Shadow Health for Danny Rivera

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