Tentamen (uitwerkingen)
Daniel Rivera _ Focused Exam: Cough Results_Turned In | NR 509 Focused_Exam_Cough_Transcript
Focused Exam: Cough Results | Turned In 
Advanced Health Assessment - Chamberlain, NR509-April-2018 
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Your Results L La ab b P Pa as ss s 
Started: Jun 04, 2018 | Patient Exam Time: 86 min 
Transcript 
Greet 
06/04/18 2:50 PM 
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Overview 
Transcript 
Subjective Data Collection 
Objective Data Collection 
Education & Empathy 
Documentation 
Self-Reflection 
I In nt te er rv viie ew w Q Qu ue es st tiio on ns s ( (7 76 6) ) S St ta at te em me en nt ts s ( (8 8) ) E Ex xa am m A Ac ct tiio on ns s ( (9 96 6) ) 
Hello, My name is Sara an FNP student and I will be interviewing you 
today 
Hi. 
What brought you into the clinic today? 
My Abuela brought me here because I've been feeling sick. I have 
been coughing a lot. . . and I feel kinda tired. 
What is your name? 
My name is Daniel Rivera, but I just go by Danny. 
And how old are you? 
I'm eight. 
What is your date of birth? 
I was born March 4th in, um . . . [Danny reports correct birth year.] 
[AUDIO COMING SOON] 
A Allll L Liin ne es s ( (1 18 80 0) )6/4/2018 Focused Exam: Cough | Completed | Shadow Health 

Empathize 
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I'm sorry you feel so bad 
Thank you. 
When did your cough start? 
I think the cough started four. . . No, it started five days ago. 
Can you describe your place to me? 
My cough seems kind of gurgly and watery. 
Do you have any sputum? 
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. 
How often are you coughing? 
I just keep feeling like I have to cough every couple minutes or so. I 
think it gets worse at night. 
How long does a cough last? 
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?.) 
My cough seems kind of gurgly and watery. 
What makes your cough worse?6/4/2018 Focused Exam: Cough | Completed | Shadow Health 

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My cough mostly stays the same no matter what I do. It seems to 
get worse at night though. 
Do you smoke? 
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.) 
What makes your cough worse? 
My cough mostly stays the same no matter what I do. It seems to 
get worse at night though. 
Are you exposed to anyone smoking? 
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. 
Does your father smoke? 
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. 
What makes your cough better? 
I had some cough medicine this morning. [AUDIO COMING SOON] 
Being exposed to secondhand smoke is almost just as bad as 
smoking, make sure you're around no one that is smoking 
Oh, OK.6/4/2018 Focused Exam: Cough | Completed | Shadow Health 

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What type of cough medicine do you take? (Clarified to Can you 
describe the cough medicine to me.) 
Um, it was purple-ish. It tasted gross. 
Do you know how much cough medicine you take? 
I just had one spoonful of it. 
Who gives you the medication? 
My mom. 
Any other things you were doing for your cough? 
My nose is a runny and I just feel kind of tired. Oh . . . my throat hurts 
a little bit too. But just a little bit. 
Are you using any home remedies for your cough? 
I had some cough medicine this morning. [AUDIO COMING SOON] 
Home remedies for cough? 
I had some cough medicine this morning. [AUDIO COMING SOON] 
Are you taking anything else for your cough? (Clarified to are you 
taking other medications.) 
I'm not taking any medicines every day. My mom gave me some 
cough medicine this morning though. 
Do you typically take medication every day? (Clarified to do you take 
any medications daily.)6/4/2018 Focused Exam: Cough | Completed | Shadow Health 

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I don't take any medicines every day. 
Do you take a vitamin? 
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! 
You really should only take one as prescribed on the bottle of gummy 
dinosaurs 
Oh, OK. 
How is your activity level? 
I have gym class every day. I do all my exercises there. Abuela 
always has to remind me to play outside for a little bit on the 
weekends. . . I guess I like to play inside more. 
How are your classes in school 
I like school, but I guess sometimes it makes me feel bored if the 
homework is too easy. 
Is it hard for you to focus? (No matching questions found.) 
Is it hard for you to focus in school? (No matching questions found.) 
how is your school focus? 
I like school, but I guess sometimes it makes me feel bored if the 
homework is too easy. 
With your cough are you still able to play? (No matching questions 
found.)6/4/2018 Focused Exam: Cough | Completed | Shadow Health 

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Is your cough interfering with your play 
I don't usually wake up once I go to bed, but my cough has made it 
hard to fall asleep. 
Does your cough make it difficult to run? 
I don't usually wake up once I go to bed, but my cough has made it 
hard to fall asleep. 
How is your activity level? 
I have gym class every day. I do all my exercises there. Abuela 
always has to remind me to play outside for a little bit on the 
weekends. . . I guess I like to play inside more. 
It is always good to have physical exercise 
Oh, OK. 
Do you have a runny nose? 
My nose is always a little bit runny... but ever since I started 
coughing it's been worse, I think. 
Sneezing? 
I don't usually have to sneeze. My nose gets runny a lot of times 
though, like I have a cold. 
How often do you have a runny nose? 
Yeah, um, my nose is runny right now... it always seems a little bit 
runny. 
What color is your nasal discharge?6/4/2018 Focused Exam: Cough | Completed | Shadow Health 

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You mean like when I blow my nose? It's clear. 
Is the drainage from your nose thin? 
My nose is always a little bit runny... but ever since I started 
coughing it's been worse, I think. 
What is the consistency of your nasal drainage? 
It's kind of clear and, like, watery. 
Are you having any pain? 
Nothing really hurts. I've just had this cough for about five days. . . 
and I feel kind of tired. 
On a Pain Scale of 0 to 10 what would you rate your pain? 
Well, I have a little pain . . . in my right ear. Maybe almost a 3. Yeah. 
It's not too bad. 
I'm sorry you're in pain 
Thank you. 
Are you having pain in your ears? 
My right ear is starting to hurt a little bit . . . my left one is OK though. 
history of ear infections? (Clarified to have you ever had ear 
infections.)6/4/2018 Focused Exam: Cough | Completed | Shadow Health 

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Empathize 
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The last time I had one was when I was little. Mom said I used to get 
them a lot. Maybe I was 2-years-old? Oh, my right ear kind of hurts 
now . . . 
Do you have any ear drainage? 
No, nothing comes out of my ears, but my right ear kind of hurts. 
I'm sorry to hear that- 
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