Focused SOAP Note For Cough Assignment Paper

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Focused SOAP Note For Cough Assignment Paper

Patient’s initials: D.R

Age: 8 years old

Sex: male

Subjective Data

Chief complain: cough

History of presenting illness: D.R, an 8 year old boy presents with a cough lasting for the last four to five days. He describes that the cough was watery and gurgly in nature, worse during the night and is not aggravated with activity. He also has a clear and watery like discharge from his nose .He also reports of fatigue which results from him not sleeping well at night. He states that he has right ear pain which he rates 3 out of 10 and mild throat soreness. Focused SOAP Note For Cough Assignment Paper

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Medications

OTC cough syrup one spoonful.

PO multivitamin tabs daily.

Past medical history

He had an ear infection when he was young.

Was treated for pneumonia last year.

Past surgical history

No history of surgery

Sexual/reproductive history

He is not sexually active.

Personal/social history

There is a positive history of secondary smoking. He reports that the father smokes cigars sometimes. During his free time, he plays video games. He washes his hands before he eats and after he goes to the bathroom.

Immunization history

He frequently gets vaccinated.

Significant family history

No history of allergies in the family. However, he reports that his father had asthma when he was a child.

Review of systems

General: positive history of fatigue. Denies fever, chills, weakness, night sweats or weight loss.

Neurological: denies headache or dizziness.

HEENT: denies episodes of nose bleeding, watery eyes, eye reddening or pain. Positive history of a runny nose and denies sinus pain. He has a positive history of right ear pain, denies hearing difficulty of discharge. There is a positive history of painful swallowing.

Respiratory: he has a positive history of cough. Denies sputum production, chest pain or tightness and difficulty in breathing.

Cardiovascular: denies shortness of breath or orthopnea.

GIT: denies abdominal pain or loss of appetite Focused SOAP Note For Cough Assignment Paper

Objective Data

Physical Exam

Vital Signs: spirometry: FEV:3.15L,FVC 3.91L, respiratory is increased.

General: D.R, 8 year old boy is stable. He however appears to be fatigued.

HEENT: the mucus membrane is clear, moist and a clear nasal discharge is noted. The eyes are dull appearance and have a pink conjunctiva. The right tympanic membrane is red and inflamed. The right cervical lymph node is enlarged and is tender on palpation. The throat is erythematous with cobble stoning in the back of the throat.

Respiratory: he is not in acute distress and is able to speak full sentences. The chest wall is resonant and breath sounds are clear bilaterally. Tactile and vocal fremitus are present bilaterally.

Cardiovascular: s1 and s2 heard. No gallops, murmurs or rubs noted.

Diagnostic Tests

Chest x-ray: assess for any abnormal findings in the cardiac and lung fields.

Allergy testing: evaluate the reactions to specific allergens.

Strep-culture: to identify the presence of group A streptococcus bacteria causing the throat symptoms.

Assessment

Asthma (J45.0): it described as a chronic inflammatory condition of the airways which is characterized by repeated episodes of airway obstruction as a result of increased mucus production edema and bronchospasm. Some of the risk factors associated with development of the disease include; personal or family history of atopy usually seen in hay fever, eczema and asthma. Triggers of the disease include; obesity viral respiratory tract infection, chronic sinusitis, tobacco smoke, stress and others. The clinical manifestation includes; cough or wheeze, usually aggravated by cold, exercise or allergies. The symptoms often worsen at night. According to Sinyor & Livasky Concepcion Perez,( 2022), majority of asthmatic patients have nocturnal coughing episodes at night but appear normal in the day time.

Allergic rhinitis (J30.9): it is characterized by inflammation of the nasal pathway that is immune mediated. It is mainly associated with conditions such as atopic dermatitis and asthma. It can be classified as seasonal or perennial. The clinical presentation includes; clear rhinorrhea, post nasal drip sneezing and watery eyes. Patients also present with non-productive cough, allergic conjunctivitis, chronic sinusitis and Eustachian tube dysfunction. Majority of these patients have a family history of allergies or a personal history of asthma (Akhouri S;House SA, 2022)Focused SOAP Note For Cough Assignment Paper. Triggers associated with the disease include; tobacco smoke, animal dander, pollen, mold, perfumes and humidity.

Pharyngitis (J02.9): it is referred to as the irritation or inflammation of the oropharynx mucous membrane. The major causes infectious and they include; bacterial, viral or rarely fungal pathogens. Other causes include; acid reflux, trauma, allergies and toxins. According to Wolford et al., (2022), the typical presentation comprises; pharyngeal erythema, painful cervical adenopathy, fever, tonsilar exudates, ear pain, and ear pain.

References

Akhouri S;House SA. (2022, January 24). Allergic Rhinitis. https://pubmed.ncbi.nlm.nih.gov/30844213/

Sinyor, B., & Livasky Concepcion Perez. (2022, May 8). Pathophysiology Of Asthma. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551579/

‌Wolford, R. W., Goyal, A., Yasin, S., & Schaefer, T. J. (2022, May 8). Pharyngitis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519550/ Focused SOAP Note For Cough Assignment Paper

‌In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

To Prepare
Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
Review the Shadow Health Resources provided in this weekâ€™s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this weekâ€™s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom. Focused SOAP Note For Cough Assignment Paper
Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Please use transcript below to fill in SOAP note
Hi.
Your avatar
How are you doing today ?
Question
10/03/20 12:38 PM MDT

Danny Rivera
I donâ€™t feel so good. I keep coughing and I feel a little bit tired.
Your avatar
Oh, Iâ€™m sorry to hear that Danny
Empathize
10/03/20 12:39 PM MDT

Danny Rivera
Thank you.
Your avatar
How is the characteristics of your cough ?
Question
10/03/20 12:40 PM MDT

Danny Rivera
My cough seems kind of gurgly and watery.
Your avatar
Do you have a cough ?
Question
10/03/20 12:48 PM MDT

Danny Rivera
I guess Iâ€™m kind of sick. . . Iâ€™ve been coughing a lot.
Your avatar
How often do you have a cough ? Focused SOAP Note For Cough Assignment Paper
Question
10/03/20 12:48 PM MDT

Danny Rivera
I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
Your avatar
When it started ? (Clarified to When did the cough start?.)
Question
10/03/20 12:49 PM MDT

Danny Rivera
I think the cough started four. . . No, it started five days ago. (Clarified to when the cough started.)
Your avatar
How frequently have you been coughing ?
Question
10/03/20 12:50 PM MDT

Danny Rivera
I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
Your avatar
Is your cough wet cough ?
Question
10/03/20 12:50 PM MDT

Danny Rivera
Yeah . . . my cough seems kind of gurgly and watery.
Your avatar
Do you have a sputum ?
Question
10/03/20 12:51 PM MDT

Danny Rivera
Sometimes I cough up this slimy, clear stuff.
Your avatar
What aggravates your cough ?
Question
10/03/20 12:51 PM MDT

Danny Rivera
My cough mostly stays the same no matter what I do. It seems to get worse at night though.
Your avatar
Do you smoke ?
Question
10/03/20 12:52 PM MDT

Danny Rivera
No way! I know smoking is really badâ€“even for grown-ups. Papi smokes cigars sometimes. I donâ€™t like how they smell.
Your avatar
Lisa poppy smokes at home around you (No matching questions found.)Focused SOAP Note For Cough Assignment Paper
Question
10/03/20 12:52 PM MDT

Your avatar
Lisa poppy smokes at home around you ? (No matching questions found.)
Question
10/03/20 12:53 PM MDT

Your avatar
Lisa Papi smokes at home around you ? (No matching questions found.)
Question
10/03/20 12:53 PM MDT

Your avatar
Is Papi smokes at home around you ?
Question
10/03/20 12:54 PM MDT

Danny Rivera
Yeah, sometimes Papi smokes cigars inside. He forgets to take them outside and my mom has to remind him. [AUDIO COMING SOON]
Your avatar
Itâ€™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.NURS6512 Week 5 â€“ Focused Exam: Cough Danny Rivera Focused SOAP Note For Cough Assignment Paper
Educate
10/03/20 1:00 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Are there anything makes your cough worse ?
Question
10/03/20 1:00 PM MDT

ORDER HERE

Danny Rivera
My cough mostly stays the same no matter what I do. It seems to get worse at night though.
Your avatar
What helps you cough ?
Question
10/03/20 1:01 PM MDT

Danny Rivera
I had some cough medicine this morning. [AUDIO COMING SOON]
Your avatar
Resting helps you ? (Clarified to Does rest relieve your cough?.)
Question
10/03/20 1:03 PM MDT

Danny Rivera
My cough has just stayed the same. Iâ€™ve taken some naps, but it doesnâ€™t seem to help. (Clarified to if rest relieves my cough.)
Your avatar
Does drinking water helps your cough ?
Question
10/03/20 1:03 PM MDT

Danny Rivera
Drinking water doesnâ€™t do anything to my cough.
Your avatar
Do you have any nasal problems ?
Question
10/03/20 1:04 PM MDT

Danny Rivera
My nose doesnâ€™t get stuffed up. Oh, sometimes it gets runny though.
Your avatar
Do you sneeze ? Focused SOAP Note For Cough Assignment Paper
Question
10/03/20 1:04 PM MDT

Danny Rivera
I donâ€™t usually have to sneeze. My nose gets runny a lot of times though, like I have a cold.
Your avatar
Do you have rhinorrhea ?
Question
10/03/20 1:05 PM MDT

Danny Rivera
I donâ€™t have a rhino. My mom wonâ€™t even let me get a lizard. [AUDIO COMING SOON]NURS6512 Week 5 â€“ Focused Exam: Cough Danny Rivera
Your avatar
Get runny nose often ?
Question
10/03/20 1:06 PM MDT

Danny Rivera
My nose is always a little bit runnyâ€¦ but ever since I started coughing itâ€™s been worse, I think.
Your avatar
Do you have a nasal discharge ?
Question
10/03/20 1:06 PM MDT

Danny Rivera
My nose is always a little bit runnyâ€¦ but ever since I started coughing itâ€™s been worse, I think.
Your avatar
Is there a discharge from your nose is clear ? (Clarified to Is the runny stuff from your nose clear?.)
Question
10/03/20 1:07 PM MDT

Danny Rivera
You mean like when I blow my nose? Itâ€™s clear. (Clarified to if my nasal discharge is clear.)Focused SOAP Note For Cough Assignment Paper
Your avatar
Is this stuff coming out from your nose is thin ? (Clarified to Is the runny stuff from your nose thick?.)
Question
10/03/20 1:08 PM MDT

Danny Rivera
Itâ€™s kind of clear and, like, watery. (Clarified to if I have thick nasal discharge.)
Your avatar
How about your ears ? (Clarified to How are your ears?.)
Question
10/03/20 1:09 PM MDT

Danny Rivera
My right ear is starting to hurt a little bit . . . my left one is OK though. (Clarified to how my ears are.)
Your avatar
Do you have any ear pain ?
Question
10/03/20 1:09 PM MDT

Danny Rivera
My right ear is starting to hurt a little bit . . . my left one is OK though.
Your avatar
How long have you had a ear pain ?
Question
10/03/20 1:10 PM MDT

Danny Rivera
My right ear just started hurting yesterday. I think itâ€™s because Iâ€™m sick.
Your avatar
What is European from 1 to 10 ? (Clarified to How would you rate your ear pain on a 0-10 scale?.)
Question
10/03/20 1:10 PM MDT

Danny Rivera
Oh, I think it just hurts a little bit . . . three? (Clarified to how I would rate my ear pain on a scale.)Focused SOAP Note For Cough Assignment Paper
Your avatar
Do you have any discharge from your ears ?
Question
10/03/20 1:11 PM MDT

Danny Rivera
No, nothing comes out of my ears, but my right ear kind of hurts.
Your avatar
Do you have any problem in your throat ?
Question
10/03/20 1:11 PM MDT

Danny Rivera
My throat is sore, but just a little bit.
Your avatar
Do you have a pain when you swallow ?
Question
10/03/20 1:11 PM MDT

Danny Rivera
No, I can swallow OK. It hurts a little right now because my throat is kinda sore.
Your avatar
What type of medication do you take ?
Question
10/03/20 1:12 PM MDT

Danny Rivera
I took some cough medicine this morning. [AUDIO COMING SOON]
Your avatar
What does the name of cough medication ? (Clarified to Do you know what the cough medicationâ€™s name is?.)
Question
10/03/20 1:12 PM MDT

Danny Rivera
I donâ€™t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON] (Clarified to if I know what the cough medicine is called.)
Your avatar
You take vitamins ? (Clarified to Do you take a multivitamin every day?.)Focused SOAP Note For Cough Assignment Paper
Question
10/03/20 1:12 PM MDT

Danny Rivera
Oh yeah, I take vitamins every day! The gummy dinosaur kind. I donâ€™t think Iâ€™m supposed to, but sometimes I sneak extra ones to be super healthy! (Clarified to if I take a vitamin every day.)NURS6512 Week 5 â€“ Focused Exam: Cough Danny Rivera
Your avatar
Itâ€™s not good to take the extra one because it is important medication or vitamins dosages and the excess amount may hurt you.
Educate
10/03/20 1:14 PM MDT

Danny Rivera
Oh, OK.
Your avatar
How you taking medication for your cough ? (Clarified to Have you taken medicine for your cough?.)
Question
10/03/20 1:14 PM MDT

Danny Rivera
I had some cough medicine this morning. [AUDIO COMING SOON] (Clarified to if I have taken medicine for my cough.)
Your avatar
What does the color of your cough medication ? (Clarified to Can you describe the cough medicine to me?.)
Question
10/03/20 1:15 PM MDT

Danny Rivera
Um, it was purple-ish. It tasted gross. (Clarified to to describe the cough medicine.)
Your avatar
What is the amount of this medication youâ€™re taking?
Question
10/03/20 1:15 PM MDT

Danny Rivera
I took some cough medicine this morning. [AUDIO COMING SOON]
Your avatar
How much of cough medication you took ? (Clarified to How much did you take of the cough medication?.)
Question
10/03/20 1:16 PM MDT

Danny Rivera
I just had one spoonful of it. (Clarified to how much cough medicine I took.)
Your avatar
Who give use a cough medicine ?
Question
10/03/20 1:16 PM MDT

Danny Rivera
My mom.
Your avatar
Itâ€™s a cough medication makes you feel better ?
Question
10/03/20 1:16 PM MDT

Danny Rivera
It helped a bit when my mom gave it to me, but my cough came back anyway.
Your avatar
Do you have any allergies ?
Question
10/03/20 1:17 PM MDT

Danny Rivera
I donâ€™t really have any allergies. Tony has some though. Heâ€™s allergic to bees.
Your avatar
Do you have any food allergies ? Focused SOAP Note For Cough Assignment Paper
Question
10/03/20 1:17 PM MDT

Danny Rivera
Iâ€™m not allergic to any foods I donâ€™t think.
Your avatar
Are you allergic to any animals ?
Question
10/03/20 1:17 PM MDT

Danny Rivera
Iâ€™m not allergic to any animals, which is good because I like them.
Your avatar
Do you have any let latex allergy ?
Question
10/03/20 1:18 PM MDT

Danny Rivera
I donâ€™t really have any allergies. Tony has some though. Heâ€™s allergic to bees.
Your avatar
Who is Tony ?
Question
10/03/20 1:18 PM MDT

Danny Rivera
Tonyâ€™s my best friend.
Your avatar
Do you have any past medical history ?
Question
10/03/20 1:18 PM MDT

Danny Rivera
Oh, well, I have been sick before and Iâ€™m sick now . . . I had pneumonia once. Last year. My mom was really scared. She says I used to get earaches a lot too.
Your avatar
Do you have any asthma ?
Question
10/03/20 1:19 PM MDT

Danny Rivera
Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I donâ€™t have to.
Your avatar
How was your immunizations ? (Clarified to What immunizations have you had?.)
Question
10/03/20 1:19 PM MDT

Danny Rivera
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. (Clarified to what vaccines I have had.)
Your avatar
Have you ever been in the hospital ?
Question
10/03/20 1:20 PM MDT

Danny Rivera
I have never been to the hospital. My mom likes to watch doctor shows on TV, so I kind of know what itâ€™s like.
Your avatar
Who smokes at home ?
Question
10/03/20 1:20 PM MDT

Danny Rivera
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 itâ€™s not all the time or anything. I donâ€™t like how it smells.
Your avatar
Where does your father smoke ?
Question
10/03/20 1:21 PM MDT

Danny Rivera
Sometimes Papi forgets to go outside with his cigars. Heâ€™s usually in the kitchen or the living room when that happens.
Your avatar
Do you have any unusual frequent colds ? Focused SOAP Note For Cough Assignment Paper
Question
10/03/20 1:21 PM MDT

Danny Rivera
I get colds a lot. My nose is always runny.
Your avatar
Do you have a fever ?
Question
10/03/20 1:21 PM MDT

Danny Rivera
My mom said I didnâ€™t have a fever this morning before Abuela took me here.
Your avatar
Do you have a chills ?
Question
10/03/20 1:21 PM MDT

Danny Rivera
No, I havenâ€™t felt that.
Your avatar
Do you have a weakness ?
Question
10/03/20 1:22 PM MDT

Danny Rivera
I havenâ€™t felt weak. . . Iâ€™m just kind of tired because my cough keeps me up at night.
Your avatar
Do you have any night sweats ?
Question
10/03/20 1:22 PM MDT

Danny Rivera
I donâ€™t sweat at night unless it gets really hot or something.
Your avatar
Have you lost weight ?
Question
10/03/20 1:22 PM MDT

Danny Rivera
I guess I gained some weight actually. Some kids at recess called me chubby . . . My mom says Iâ€™m just growing though.
Your avatar
How is your appetite ?
Question
10/03/20 1:23 PM MDT

Danny Rivera
I think my appetite is normal.
Your avatar
Do you have any ear crackling or popping ?
Question
10/03/20 1:23 PM MDT

Danny Rivera
No, I havenâ€™t noticed any popping in my ears, but my right ear kind of hurts.
Your avatar
Do you have any popping sounds ?
Question
10/03/20 1:23 PM MDT

Danny Rivera
No, I havenâ€™t noticed any popping in my ears, but my right ear kind of hurts.
Your avatar
Have you ever had any ear infections ?
Question
10/03/20 1:24 PM MDT

Danny Rivera
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 . . .
Your avatar
Have you ever had any surgery on your ears?
Question
10/03/20 1:24 PM MDT

Danny Rivera
Mom says I used to get ear infections a lot when I was little, but Iâ€™m pretty sure I never had surgery for it.NURS6512 Week 5 â€“ Focused Exam: Cough Danny Rivera
Your avatar
Do you get headaches ? Focused SOAP Note For Cough Assignment Paper
Question
10/03/20 1:24 PM MDT

Danny Rivera
I donâ€™t usually get headaches.
Your avatar
Do you have nose bleeds ?
Question
10/03/20 1:24 PM MDT

Danny Rivera
Just one time. Tony and I were kicking a ball at recess and I got hit in the nose.
Your avatar
Do you get dizzy ?
Question
10/03/20 1:25 PM MDT

Danny Rivera
I only get dizzy if Iâ€™m spinning around a lot at recess.
Your avatar
Your eyes getting watery ?
Question
10/03/20 1:25 PM MDT

Danny Rivera
No, my eyes donâ€™t tear up. Well, I guess if I get sad or Papi is chopping onions for dinner they might.
Your avatar
Is your eyes getting red?
Question
10/03/20 1:25 PM MDT

Danny Rivera
I donâ€™t think my eyes are ever red.
Your avatar
Do you have eye pain?
Question
10/03/20 1:25 PM MDT

Danny Rivera
No, my eyes donâ€™t hurt, but they kind of feel like they do when Iâ€™m tired.
Your avatar
Do you have any sinus pain?
Question
10/03/20 1:26 PM MDT

Danny Rivera
It doesnâ€™t hurt there.
Your avatar
Do you have hearing problems ?
Question
10/03/20 1:26 PM MDT

Danny Rivera
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 . . .
Your avatar
How was your breathing ?
Question
10/03/20 1:26 PM MDT

Danny Rivera
My breathing seems good. My nose is kind of runny right now, but I can still breathe OK.
Your avatar
Do you have any chest tightness?
Question
10/03/20 1:26 PM MDT

Danny Rivera
My chest feels okay.
Your avatar
Do you have any chest pain ?
Question
10/03/20 1:27 PM MDT

Danny Rivera
No, I donâ€™t have pain in my chest. I would hate that!
Your avatar
Have you ever had any medications at in you inhaled ? (Clarified to Have you used an inhaler?.)Focused SOAP Note For Cough Assignment Paper
Question
10/03/20 1:27 PM MDT

Danny Rivera
No, I donâ€™t use one of those. My friend Tony does though! (Clarified to if I have used an inhaler.)
Your avatar
Is anybody sick in your house ?
Question
10/03/20 1:28 PM MDT

Danny Rivera
Nobody at home is sick I donâ€™t think.
Your avatar
Do you have any family history of asthma ?
Question
10/03/20 1:28 PM MDT

Danny Rivera
Mom says Papi had asthma when he was a little kid.
Your avatar
Anybody in your family has allergies ?
Question
10/03/20 1:28 PM MDT

Danny Rivera
I donâ€™t think so, but I guess Iâ€™m not sure.
Your avatar
Do you have any pets at home ?
Question
10/03/20 1:29 PM MDT

Danny Rivera
No, but I keep asking my mom if I can get a lizard.
Your avatar
Where do you go when you have a free time ? (No matching questions found.)
Question
10/03/20 1:30 PM MDT

Your avatar
What do you do when you have a free time ?
Question
10/03/20 1:30 PM MDT

Danny Rivera
Usually I play video games or read or try to write stories. If Tony is here, we do that stuff together.
Your avatar
How often you around smoking people ? (Clarified to How often are you around people who smoke?.)Focused SOAP Note For Cough Assignment Paper
Question
10/03/20 1:31 PM MDT

Danny Rivera
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 itâ€™s not all the time or anything. I donâ€™t like how it smells. (Clarified to how often I am around secondhand smoke.)
Your avatar
Do you wash your hands ?
Question
10/03/20 1:38 PM MDT

Danny Rivera
I wash my hands before I eat or after I go to the bathroom.
Your avatar
How often do you wash your hands?
Question
10/03/20 1:39 PM MDT

Danny Rivera
I wash my hands before I eat or after I go to the bathroom.
Your avatar
Do you touch your nose often ?
Question
10/03/20 1:39 PM MDT

Danny Rivera
My nose is always a little bit runnyâ€¦ but ever since I started coughing itâ€™s been worse, I think.
Your avatar
You need to wash your hands more often.When you come from somewhere.
Educate
10/03/20 1:40 PM MDT

Danny Rivera
Oh, OK.
Your avatar
You need to wash your hands after you touch your nose. You may transfer a lot of infections or bacteria from your nose to door handles for example. If you dont wash your hands more often you can contaminate yourself or others with bacteria and possible viruses fro unwashed hands.NURS6512 Week 5 â€“ Focused Exam: Cough Danny Rivera
Educate
10/03/20 1:44 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Checked vitals
Exam Action
10/03/20 1:44 PM MDT

Your avatar
Tested lung capacity with spirometer: FEV1: 1.78L, FVC 1.549L (FEV1/FVC: 87%)
Exam Action
10/03/20 1:46 PM MDT

Your avatar
Inspected mouth
Exam Action
10/03/20 1:48 PM MDT

Your avatar
Inspected front of neck
Exam Action
10/03/20 1:48 PM MDT

Your avatar
Inspected anterior chest wall
Exam Action
10/03/20 1:48 PM MDT

Your avatar
Palpated maxillary sinuses: No tenderness reported
Exam Action
10/03/20 1:49 PM MDT

Your avatar
Palpated frontal sinuses: No tenderness reported
Exam Action
10/03/20 1:49 PM MDT

Your avatar
Palpated maxillary sinuses: No tenderness reported
Exam Action
10/03/20 1:49 PM MDT

Your avatar
Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side
Exam Action
10/03/20 1:50 PM MDT

Your avatar
Palpated axillary lymph nodes: Not palpable
Exam Action
10/03/20 1:50 PM MDT

Your avatar
Palpated supraclavicular lymph nodes: Not palpable
Exam Action
10/03/20 1:50 PM MDT

Your avatar
Palpated axillary lymph nodes: Not palpable
Exam Action
10/03/20 1:50 PM MDT

Your avatar
Palpated supraclavicular lymph nodes: Not palpable
Exam Action
10/03/20 1:51 PM MDT

Your avatar
Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally
Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally
Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally
Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
Palpated fremitus in posterior upper chest wall: Expected fremitus, equal bilaterally
Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
Palpated fremitus in posterior middle chest wall: Expected fremitus, equal bilaterally
Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally
Exam Action
10/03/20 1:51 PM MDT

Your avatar
Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally
Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally
Exam Action
10/03/20 1:51 PM MDT

Danny Rivera
Ninety-nine.
Your avatar
Auscultated breath sounds in anterior right upper lobe
Exam Action
10/03/20 1:52 PM MDT

Your avatar
Auscultated breath sounds in anterior left upper lobe
Exam Action
10/03/20 1:52 PM MDT

Your avatar
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Exam Action
10/03/20 1:52 PM MDT

Your avatar
Auscultated breath sounds in anterior right middle lobe
Exam Action
10/03/20 1:52 PM MDT

Your avatar
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Exam Action
10/03/20 1:52 PM MDT

Your avatar
Auscultated breath sounds in anterior right middle lobe
Exam Action
10/03/20 1:52 PM MDT

Your avatar
Auscultated breath sounds in anterior right lower lobe
Exam Action
10/03/20 1:53 PM MDT

Your avatar
Auscultated breath sounds in anterior left lower lobe
Exam Action
10/03/20 1:53 PM MDT

Your avatar
Auscultated breath sounds in posterior right upper lobe
Exam Action
10/03/20 1:53 PM MDT

Your avatar
Auscultated breath sounds in posterior left upper lobe
Exam Action
10/03/20 1:53 PM MDT

Your avatar
Auscultated breath sounds in posterior left mid-back (lower lobe)
Exam Action
10/03/20 1:53 PM MDT

Your avatar
Auscultated breath sounds in posterior right mid-back (lower lobe)
Exam Action
10/03/20 1:53 PM MDT

Your avatar
Auscultated breath sounds in posterior left lower lobe near spine
Exam Action
10/03/20 1:53 PM MDT

Your avatar
Auscultated breath sounds in posterior right lower lobe near spine
Exam Action
10/03/20 1:53 PM MDT

Your avatar
Auscultated breath sounds in posterior right lower lobe
Exam Action
10/03/20 1:54 PM MDT

Your avatar
Auscultated breath sounds in posterior left lower lobe
Exam Action
10/03/20 1:54 PM MDT

Your avatar
Auscultated breath sounds in posterior left lower lobe on side
Exam Action
10/03/20 1:54 PM MDT

Your avatar
Auscultated breath sounds in posterior right lower lobe on side
Exam Action
10/03/20 1:54 PM MDT

Your avatar
Auscultated breath sounds in anterior left upper lobe
Exam Action
10/03/20 1:54 PM MDT

Your avatar
Auscultated breath sounds in anterior right upper lobe
Exam Action
10/03/20 1:54 PM MDT

Your avatar
Auscultated breath sounds in anterior right middle lobe
Exam Action
10/03/20 1:54 PM MDT

Your avatar
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Exam Action
10/03/20 1:54 PM MDT

Your avatar
Auscultated breath sounds in anterior right middle lobe
Exam Action
10/03/20 1:54 PM MDT

Your avatar
Auscultated breath sounds in anterior right lower lobe
Exam Action
10/03/20 1:54 PM MDT

Your avatar
Percussed anterior right upper lobe
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed anterior left upper lobe
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed anterior right middle lobe
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed anterior left mid-chest (upper lobe)
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed anterior left lower lobe
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed anterior right lower lobe
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed posterior right upper lobe
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed posterior left upper lobe
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed posterior left mid-back (lower lobe)
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed posterior right mid-back (lower lobe)
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed posterior right lower lobe
Exam Action
10/03/20 1:55 PM MDT

Your avatar
Percussed posterior right lower lobe near spine
Exam Action
10/03/20 1:56 PM MDT

Your avatar
Percussed posterior left right lobe on side
Exam Action
10/03/20 1:56 PM MDT

Your avatar
Percussed posterior left lower lobe near spine
Exam Action
10/03/20 1:56 PM MDT

Your avatar
Percussed posterior left lower lobe
Exam Action
10/03/20 1:56 PM MDT

Your avatar
Percussed posterior left lower lobe on side
Exam Action
10/03/20 1:56 PM MDT

Your avatar
Checked vitals
Exam Action
10/03/20 1:56 PM MDT

Your avatar
Do you have sick friends ?
Question
10/03/20 5:03 PM MDT

Danny Rivera
None of my friends are sick that I know of.
Your avatar
Do you have anybody passing it around you ? (No matching questions found.)
Question
10/03/20 5:04 PM MDT

Your avatar
Do you have your friend Tony coughing around you ? (Clarified to Is tony sick?.)
Question
10/03/20 5:04 PM MDT

Danny Rivera
None of my friends are sick that I know of. (Clarified to if Tony is sick.)
Your avatar
Are you touching your nose ? (No matching questions found.)
Question
10/03/20 5:05 PM MDT

Your avatar
How often do you touch your nose ? (Clarified to How often do you blow your nose?.)
Question
10/03/20 5:05 PM MDT

Danny Rivera
Probably a million-billion times a day. [AUDIO COMING SOON] (Clarified to how often I blow my nose.)
Your avatar
Danny, signs you have been sick for last few days itâ€™s very important that you practice strict hand hygiene and respiratory hygiene because you can develop upper respiratory infection. It is extremely important to prevent it.NURS6512 Week 5 â€“ Focused Exam: Cough Danny Rivera
Educate
10/03/20 5:10 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Is anybody in your class sick ?
Question
10/03/20 5:35 PM MDT

Danny Rivera
Nobody I know is sick, I donâ€™t think.
Your avatar
How is the Tony feels ?
Question
10/03/20 5:36 PM MDT

Danny Rivera
None of my friends are sick that I know of.
Your avatar
What type of diet do you have ?
Question
10/03/20 5:39 PM MDT

Danny Rivera
Mom says Iâ€™m picky. I can clean my plateâ€¦ if I like the food. Yeah. I eat breakfast and I eat all my dinner.
Your avatar
What do you like to eat for breakfast ?
Question
10/03/20 5:39 PM MDT

Danny Rivera
I have cereal with milk and fruit most mornings. Sometimes I have a waffle or eggs and bacon.
Your avatar
Do you do exercises ?
Question
10/03/20 5:39 PM MDT

Danny Rivera
I have gym class every day. I do all my exercises there. And thereâ€™s a park right next to my house where I play after school, or sometimes on the weekends, if itâ€™s nice outside. [AUDIO COMING SOON]
Your avatar
Can you minimize the amount of waffle and bacon which is not good for your health. It is low in nutritions and high in fats and carbohydrates.
Educate
10/03/20 5:44 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Also I would like to recommend you to increase your fluid intake. It will help your body to be clean and to get rid of bacterias and infections.
Educate
10/03/20 5:47 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Inspected mouth
Exam Action
10/04/20 3:15 AM MDT

Your avatar
Can I take a look at your mouth again ?
Question
10/04/20 3:16 AM MDT

Danny Rivera
Sure.
Your avatar
Performed otoscopic examination of right ear
Exam Action
10/04/20 3:17 AM MDT

Your avatar
Can I examine you more Danny ?
Question
10/04/20 3:18 AM MDT

Danny Rivera
Sure.
Your avatar
Performed otoscopic examination of left ear
Exam Action
10/04/20 3:18 AM MDT

Your avatar
Performed otoscopic examination of right ear
Exam Action
10/04/20 3:18 AM MDT

Your avatar
Performed otoscopic examination of left ear
Exam Action
10/04/20 3:19 AM MDT

Your avatar
Inspected mouth
Exam Action
10/04/20 3:29 AM MDT

Your avatar
Danny how often you washing your hands ?
Question
10/04/20 1:37 PM MDT

Danny Rivera
I wash my hands before I eat or after I go to the bathroom.
Your avatar
You need to wash your hands more often or to use hand sanitizer.
Educate
10/04/20 1:38 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Do you play with a sick peer ?
Question
10/04/20 1:38 PM MDT

Danny Rivera
I have a lot of girls that are friends, but no girlfriends really. Not yet! There are some girls I think are pretty though.
Your avatar
When your cough started ?
Question
10/04/20 1:39 PM MDT

Danny Rivera
I think the cough started four. . . No, it started five days ago.
Your avatar
Where do you have your pain ?
Question
10/04/20 1:40 PM MDT

Danny Rivera
My right ear kind of hurts . . . but itâ€™s just my cough that has been keeping me up at night. Oh, well, my throat is a little bit sore.
Your avatar
Do you have any discharge from your right ear ?
Question
10/04/20 1:41 PM MDT

Danny Rivera
No, nothing comes out of my ears, but my right ear kind of hurts.
Your avatar
Do you have sore throat ?
Question
10/04/20 1:41 PM MDT

Danny Rivera
It feels a little bit sore, yeah.
Your avatar
How would you describe your pain ?
Question
10/04/20 1:41 PM MDT

Danny Rivera
Um. . . I donâ€™t know. It just hurts. But itâ€™s not so bad.
Your avatar
In a scale from 1 to 10 how would you describe your pain ? (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)
Question
10/04/20 1:41 PM MDT

Danny Rivera
Well, I have a little pain . . . in my right ear. Maybe almost a 3. Yeah. Itâ€™s not too bad. (Clarified to how I would rate my pain on a scale.)
Your avatar
Do you take something for pain ? (Clarified to Are you taking anything for pain?.)
Question
10/04/20 1:42 PM MDT

Danny Rivera
I donâ€™t take medicine for pain. I only take the medicine my mom or Abuela give me. (Clarified to if I am taking pain medication.)
Your avatar
Who is Abuela ?
Question
10/04/20 1:42 PM MDT

Danny Rivera
Abuela is my grandma . . . sheâ€™s my momâ€™s mom!
Your avatar
Did you say your pain like watery and gurgle ? (No matching questions found.)NURS6512 Week 5 â€“ Focused Exam: Cough Danny Rivera
Question
10/04/20 1:43 PM MDT

Your avatar
Did you say your pain like watery and gurgle ? (No matching questions found.)
Question
10/04/20 1:43 PM MDT

Your avatar
Did you say that your pain pills like watery ? (No matching questions found.)
Question
10/04/20 1:44 PM MDT

Your avatar
How was your pain in your throat feels like ?
Question
10/04/20 1:44 PM MDT

Danny Rivera
Um, it just feels kind of sore. I can feel it a little bit when I swallow.
Your avatar
Oh, I am sorry to hear that Danny.
Empathize
10/04/20 1:46 PM MDT

Danny Rivera
Thank you.
Your avatar
Danny how much water do you take ?
Question
10/04/20 1:59 PM MDT

Danny Rivera
I drink water a lot. . . whenever Iâ€™m not drinking it enough, Abuela always makes me drink more.
Your avatar
How many cups of water do you drink per day ?
Question
10/04/20 2:00 PM MDT

Danny Rivera
I usually have 7 or 8 glasses of water a day.
Your avatar
Is Tony used uses an inhaler ? (Clarified to Is Tony your brother?.)
Question
10/04/20 2:07 PM MDT

Danny Rivera
Tonyâ€™s my best friend. (Clarified to if Tony is my brother.)
Your avatar
Do you know is Tony uses inhaler
Question
10/04/20 2:08 PM MDT

Danny Rivera
None of my friends are sick that I know of.
Your avatar
Danny you need to stay away from sick people ok ?
Educate
10/04/20 5:05 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Danny, if you see that people around you coughing and sneezing you dont need to keep close communications with them. Also I will let your parents to provide you with hand sanitizer, you need to use it after using bathroom, if you touched some doors or any other interactions and touching other things.
Educate
10/04/20 5:09 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Also drink plenty of fluids are very important for your body. It will help to loosen the mucus in your nose and help congestion when you have symptoms of infections like you do now.
Educate
10/04/20 5:13 PM MDT

Danny Rivera
Oh, OK.
Your avatar
When you cough, you need to cough into the tissue. If you dont have a tissue, use the sleeve to cover the mouth.
Educate
10/04/20 5:15 PM MDT

Danny Rivera
Oh, OK.
Your avatar
I am going to tell your father not to smoke in the house. You remind him too if he forgets or go to other room. I will follow up about it.
Educate
10/04/20 5:21 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Danny I would like to communicate with your parents about todays recommendations and schedule follow up appointment. Are you ok with that ? (No matching questions found.)
Question
10/04/20 5:24 PM MDT

Your avatar
Danny, I would like to communicate with your parents about todays recommendations and schedule follow up appointment.NURS6512 Week 5 â€“ Focused Exam: Cough Danny Rivera
Educate
10/04/20 5:24 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Also, please do not touch your face, nose, mouth, eyes with your hands. You can transmit more infection to yourself and others which we need to prevent. (No matching questions found.)
Question
10/04/20 5:26 PM MDT

Your avatar
Also, please do not touch your face, nose, mouth, eyes with your hands. You can transmit more infection to yourself and others which we need to prevent.
Educate
10/04/20 5:26 PM MDT

Danny Rivera
Oh, OK.
Your avatar
Do you have a pain now ? (Clarified to Do you have pain right now?.)
Question
10/04/20 5:27 PM MDT

Danny Rivera
The only thing that really hurts is my right ear, but it just hurts a little bit. It just started . . . Iâ€™m not sure what will make it feel better. (Clarified to if I am in pain right now.)
Your avatar
Iâ€™m sorry to hear that
Empathize
10/04/20 5:27 PM MDT

Danny Rivera
Thank you.
Your avatar
How often do you said you are coughing ?
Question
10/04/20 5:27 PM MDT

Danny Rivera
I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
Your avatar
Iâ€™m sorry it must be really uncomfortable.
Empathize
10/04/20 5:28 PM MDT

Danny Rivera
Thank you.
Your avatar
What type of medication are you taking for your cough ?
Question
10/04/20 5:47 PM MDT

Danny Rivera
I took some cough medicine this morning. [AUDIO COMING SOON]
Your avatar
What type of medication is this ? (Clarified to What medications do you take?.)
Question
10/04/20 5:47 PM MDT

Danny Rivera
I took some cough medicine this morning. [AUDIO COMING SOON] (Clarified to what medications I am taking.)
Your avatar
Do you know what is the name of this medication ? (Clarified to What is the name of the cough medicine you took?.)
Question
10/04/20 5:48 PM MDT

Danny Rivera
I donâ€™t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON] (Clarified to what the name of the cough medicine is.)
Your avatar
do you know the name of the medication for the cough ?
Question
10/04/20 5:49 PM MDT

Danny Rivera
I donâ€™t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON]
Your avatar
ok, I can ask your mom about it. (No matching questions found.)
Question
10/04/20 5:49 PM MDT

Your avatar
How long does medication was relieving your symptoms ? (No matching questions found.)
Question
10/04/20 5:50 PM MDT

Your avatar
How long does cough medication was relieving your symptoms ?
Question
10/04/20 5:50 PM MDT

ORDER NOW

Danny Rivera
My mom gave me some medicine and it helped my cough a little bit, but it started again.
Your avatar
How long you tipped you feel better after taking this medication ? (Clarified to Did the medicine make your cough better?.)
Question
10/04/20 5:51 PM MDT

Danny Rivera
It helped a bit when my mom gave it to me, but my cough came back anyway. (Clarified to if the medicine helped my cough.)Focused SOAP Note For Cough Assignment Paper