Danny Rivera Focused Exam: Cough Results – Health Assessment – January 2023
Danny Rivera Focused Exam: Cough Results – Health Assessment – January 2023
Transcript
All Lines (141)Interview Questions (37)Statements (2)Exam Actions (102)
| Hello! |
| Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. |
| What is the situation? |
| Your patient is Danny Rivera, an 8-year-old Puerto Rican boy presenting with a cough in the Shadowville Elementary nurse’s office. Your role in this simulation is that of a healthcare provider who will perform a focused history and physical examination in order to collect data, assess Danny’s condition, and transfer care. In this simulation, you will be able to perform procedures not always typical to a school setting so you can gather as much data as possible. |
| What are my objectives in this assessment? |
| Danny is very health literate and a good historian of his own health history; he can answer questions that not every child may be able to. In your interview with Danny, you will ask about the history of his presenting illness and the functioning of relevant systems in order to obtain subjective data related to his cough. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Danny’s family so you can determine his genetic predisposition to any diseases. In addition to collecting subjective data, you will perform a physical exam on Danny to gather objective data about his health and physiology. Throughout the conversation, you should educate and empathize with Danny when appropriate to increase his health literacy and sense of well-being. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. |
| What else will this exam involve? |
| Because Danny is a pediatric patient, you will also be required to make a phone call to his guardian’s home to gather additional information. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. After the exam, you will transfer care of the patient to me, Preceptor Diana, communicating key information about the Situation, Background, Assessment, and Recommendation, or SBAR. Activities other than Subjective and Objective Data Collection, and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation. |
| How will I be evaluated? |
| In this assignment, you will be evaluated on your Subjective and Objective Data Collection, as well as Education and Empathy. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. This assignment takes on average between 40 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically. |
| How does this assignment prepare me for the real world? |
| In this assessment, you will become familiarized with the structure and content of a cough focused exam so that with real-life patients, you can: º ask effective and comprehensive questions º educate and empathize with the patient º evaluate the patient’s risk of disease, infection, injury, and complications º obtain and assess objective data. º and transfer patient care using SBAR. |
| In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What strategies can you use to develop rapport with a pediatric patient? |
| Being friendly to the patient by being an active listener, repeating what the patient said and showing the patient you understand what they mean. |
| Time to begin. |
| Washed hands. |
| Hello, my name is Nukol. I will be your nurse today. |
| Hi. |
| What brings you here today? |
| My music teacher Mr. Hillman sent me here because he said I look sick. I have been coughing a lot. . . and I feel kinda tired. |
| I am sorry to hear that |
| Thanks. |
| When did the cough start? |
| I think the cough started two . . . No, it started three days ago. |
| How frequent is the cough? |
| I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night. |
| What is the characteristics of the cough? |
| My cough seems kind of gurgly and watery. |
| What aggravates the cough? |
| I don’t think anything makes my cough be worse. |
| What relieves the cough? |
| My mom gave me some medicine this morning. . . that helped my cough a little. I don’t remember what it was called though, sorry. |
| What are the nasal symptoms? |
| My nose is runny. It’s runny a lot of the time. |
| Do you have nasal discharge? |
| My nose is always a little bit runny. . .but ever since I started coughing it’s been worse, I think. |
| what colour is the nasal discharge? |
| You mean like when I blow my nose? It’s clear. |
| Do you have any ear discharge? |
| No, nothing comes out of my ears. |
| Do you have any ear pain? |
| My ears are okay. They don’t hurt or anything. |
| Do you have throat problem? |
| My throat is a little bit sore, but just a little bit. |
| Do you have any allergies? |
| I don’t think I have any allergies. |
| Have you sort any medication? (Clarified to Do you have medical problems?.) |
| Oh, well, I have been sick before and I’m sick now . . . I had pneumonia once. Last year. My mom was really scared. She says I used to get earaches a lot too. (Clarified to if I have medical problems.) |
| Have you taken any medication? |
| My mom gave me some medicine this morning. . . that helped my cough a little. I don’t remember what it was called though, sorry. |
| What colour was the medicine? |
| Um, it was purple-ish. It tasted gross. |
| Have you taken any home medications? (Clarified to Have you taken medicine for your cough?.) |
| My mom gave me some medicine this morning. . . that helped my cough a little. I don’t remember what it was called though, sorry. (Clarified to if I have taken medicine for my cough.) |
| Do you have any medical history? |
| Oh, well, I have been sick before and I’m sick now . . . I had pneumonia once. Last year. My mom was really scared. She says I used to get earaches a lot too. |
| Are you exposed to secondhand 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, and I don’t like that he is hurting himself. He could get sick. |
| Secondhand smoke exposure can be harmful to you |
| OK. |
| How is your living condition? |
| My cough seems kind of gurgly and watery. |
| Where do you live? |
| I live in Shadowville. |
| do you have breathing problem? |
| I breathe OK, but my nose is always kinda runny. |
| Have you exposed yourself to germs? (No matching questions found.) |
| Were you exposed to germs? |
| Um… no… [AUDIO COMING SOON] |
| Do you wash hands frequently? |
| Not a lot. I only wash them if they’re really dirty, or Abuela says we’re about to eat. |
| How is your cough etiquette? |
| My cough seems kind of gurgly and watery. |
| Do you cover your mouth while coughing? (Clarified to Do you cover your mouth when you cough?.) |
| When I cough, I like to let it all out. (Clarified to if I cover my mouth when I cough.) |
| Did you play with an ill child? |
| Cindy was coughing when she was at my house the other day. But she still beat me at checkers. |
| Do you take vitamins? |
| 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! |
| Do you play in school? (Clarified to Do you do a lot of playing?.) |
| I don’t play any sports on a team, but Tony and I play outside. We like to skateboard and shoot hoops. (Clarified to if I do a lot of playing.) |
| Any relevant family history? |
| My mom’s got diabetes, cholesterol, and high blood pressure. Papi talks about his cholesterol sometimes, and he smokes cigars. I know that’s bad, especially because mom says he had asthma when he was little. Probably my age. Uch, it sounds like a lot when I say it altogether like that. . . |
| Measured blood pressure |
| Measured heart rate |
| Measured pulse oximetry |
| Measured respiratory rate |
| Measured temperature |
| Tested lung capacity with spirometer: FEV1: 1.549 L, FVC 1.78 L (FEV1/FVC: 87%) |
| Inspected right orbital area and sclera |
| Inspected left orbital area and sclera |
| Inspected upper conjunctiva |
| Inspected lower conjunctiva |
| Performed otoscopic examination of right ear |
| Performed otoscopic examination of left ear |
| Performed otoscopic examination of right naris |
| Performed otoscopic examination of left naris |
| Inspected mouth |
| Inspected front of neck |
| Inspected left side of neck |
| Inspected front of neck |
| Inspected right side of neck |
| Inspected back of neck |
| Inspected left side of neck |
| Inspected back of neck |
| Inspected right side of neck |
| Inspected front of neck |
| Inspected anterior chest wall |
| Inspected posterior chest wall |
| Inspected anterior chest wall |
| Palpated frontal sinuses: No tenderness reported |
| Palpated frontal sinuses: No tenderness reported |
| Palpated maxillary sinuses: No tenderness reported |
| Palpated lymph nodes of head and neck: Enlarged and reported tenderness on the right side |
| Palpated supraclavicular lymph nodes: Not palpable |
| Palpated axillary lymph nodes: Not palpable |
| Palpated supraclavicular lymph nodes: Not palpable |
| Palpated fremitus in anterior upper chest wall: Present and equal bilaterally |
| Ninety-nine. |
| Palpated fremitus in anterior lower chest wall: Present and equal bilaterally |
| Ninety-nine. |
| Palpated fremitus in posterior upper chest wall: Present and equal bilaterally |
| Ninety-nine. |
| Palpated fremitus in posterior middle chest wall: Present and equal bilaterally |
| Ninety-nine. |
| Palpated fremitus in posterior lower chest wall: Present and equal bilaterally |
| Ninety-nine. |
| Palpated chest expansion: Both sides rise symmetrically |
| Auscultated breath sounds in anterior right upper lobe |
| Auscultated breath sounds in anterior left upper lobe |
| Auscultated breath sounds in anterior right upper lobe |
| Auscultated breath sounds in anterior left middle lobe |
| Auscultated breath sounds in anterior right middle lobe |
| Auscultated breath sounds in anterior left middle lobe |
| Auscultated breath sounds in anterior right lower lobe |
| Auscultated breath sounds in anterior left lower lobe |
| Auscultated breath sounds in posterior left upper lobe |
| Auscultated breath sounds in posterior right upper lobe |
| Auscultated breath sounds in posterior left mid-back (lower lobe) |
| Auscultated breath sounds in posterior right mid-back (lower lobe) |
| Auscultated breath sounds in posterior left lower lobe near spine |
| Auscultated breath sounds in posterior right lower lobe near spine |
| Auscultated breath sounds in posterior left lower lobe on side |
| Auscultated breath sounds in posterior left lower lobe |
| Auscultated breath sounds in posterior right lower lobe |
| Auscultated breath sounds in posterior right lower lobe on side |
| Auscultated voice sounds in anterior right upper lobe |
| Auscultated voice sounds in anterior left upper lobe |
| Auscultated voice sounds in anterior right upper lobe |
| Auscultated voice sounds in anterior left mid-chest (upper lobe) |
| Ninety-nine. |
| Ninety-nine. |
| Auscultated voice sounds in anterior right middle lobe |
| Auscultated voice sounds in anterior left mid-chest (upper lobe) |
| Auscultated voice sounds in anterior left lower lobe |
| Auscultated voice sounds in anterior right lower lobe |
| Auscultated voice sounds in posterior left upper lobe |
| Ninety-nine. |
| Auscultated voice sounds in posterior right upper lobe |
| Auscultated voice sounds in posterior left mid-back (lower lobe) |
| Auscultated voice sounds in posterior right mid-back (lower lobe) |
| Ninety-nine. |
| Ninety-nine. |
| Auscultated voice sounds in posterior right lower lobe near spine |
| Ninety-nine. |
| Auscultated voice sounds in posterior left lower lobe near spine |
| Ninety-nine. |
| Auscultated voice sounds in posterior left lower lobe on side |
| Auscultated voice sounds in posterior left lower lobe |
| Ninety-nine. |
| Auscultated voice sounds in posterior right lower lobe |
| Ninety-nine. |
| Auscultated voice sounds in posterior right lower lobe on side |
| Ninety-nine. |
| Auscultated aortic area with the bell |
| Auscultated pulmonic area with the bell |
| Auscultated pulmonic area with the diaphragm |
| Auscultated Erb’s point with the diaphragm |
| Auscultated tricuspid area with the diaphragm |
| Auscultated tricuspid area with the bell |
| Auscultated mitral area with the bell |
| Auscultated mitral area with the diaphragm |
| Percussed anterior right upper lobe |
| Percussed anterior left upper lobe |
| Percussed anterior right middle lobe |
| Percussed anterior left mid-chest (upper lobe) |
| Percussed anterior right lower lobe |
| Percussed anterior left lower lobe |
| Percussed posterior left upper lobe |
| Percussed posterior right upper lobe |
| Percussed posterior left mid-back (lower lobe) |
| Percussed posterior right mid-back (lower lobe) |
| Percussed posterior left lower lobe |
| Percussed posterior right lower lobe |
| Percussed posterior left lower lobe on side |
| Percussed posterior left lower lobe near spine |
| Percussed posterior right lower lobe near spine |
| Percussed posterior left right lobe on side |
| Measured diaphragmatic excursion: 3 cm |
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Subjective Data Collection: 22 of 22 (100.0%)
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports cough
(Found)
Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source.
Example Question:
Do you have a cough?
History of Presenting Illness
Finding:
Asked about onset of cough
Finding:
Reports cough started 3 days ago
(Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, in this case the patient’s cough, inquiring about onset assesses the severity and the progression of the problem.
Example Question:
How long have you had a cough?
Finding:
Asked about characteristics of cough
Finding:
Reports cough is wet
(Found)
Pro Tip: The characteristics of a cough, such as whether it is dry or wet, can indicate key information about the type of illness the patient has.
Example Question:
Is your cough a wet cough?
Finding:
Reports clear sputum with cough
(Found)
Pro Tip: The characteristics of a cough, such as whether it is productive, can indicate key information about the type of illness the patient has.
Example Question:
Do you produce any phlegm or sputum with your cough?
Finding:
Asked about frequency and duration of cough
Finding:
Reports coughing every few minutes
(Found)
Pro Tip: Establishing how frequently Danny coughs will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
How frequently are you coughing?
Finding:
Reports coughs last a few seconds
(Available)
Pro Tip: Establishing how long Danny’s coughs last will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
How long do your coughs last?
Finding:
Asked about aggravating factors for cough
Finding:
Reports cough is worse at night
(Found)
Pro Tip: Establishing a timeline for Danny’s coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
Is the cough worse at night?
Finding:
Denies smoking
(Available)
Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking even young patients about whether they consume tobacco products helps you assess this risk factor.
Example Question:
Do you smoke?
Finding:
Reports being exposed to secondhand smoke through father
(Found)
Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking about whether a patient is exposed to secondhand smoke allows you to assess this risk factor.
Example Question:
Are you ever around cigarette smoke?
Finding:
Reports he doesn’t know what triggers the cough
(Found)
Pro Tip: Asking about aggravating factors of Danny’s cough will allow you to determine potential causes and educate the patient on what to avoid.
Example Question:
What makes your cough worse?
Finding:
Asked about exposure to germs
Finding:
Reports playing with an ill classmate
(Found)
Pro Tip: Asking about Danny’s exposure to illnesses will allow you to counsel him on effective hygiene, as well as potentially determine the cause of his current symptoms.
Example Question:
Have you come in contact with anyone sick?
Finding:
Asked about hand hygiene
Finding:
Reports infrequent hand washing
(Found)
Pro Tip: Asking about Danny’s hand washing practices will allow you to counsel him on effective hygiene.
Example Question:
How often do you wash your hands?
Finding:
Reports occasionally putting fingers in eyes, nose, or mouth
(Available)
Pro Tip: Asking about Danny’s hand washing practices will allow you to counsel him on effective hygiene.
Example Question:
Do you ever touch your eyes, nose, or mouth?
Finding:
Asked about cough etiquette
Finding:
Denies covering mouth when coughing
(Found)
Pro Tip: Asking about Danny’s cough etiquette will allow you to counsel him on effective hygiene and reduce the risk of him infecting other people.
Example Question:
Do you cover your mouth when you cough?
Finding:
Asked about relieving factors for cough
Finding:
Reports cough is temporarily relieved by cough medicine
(Found)
Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices.
Example Question:
Have you done anything to treat your cough?
Finding:
Followed up on cough medicine
Finding:
Reports cough medicine was purple
(Found)
Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the cough medicine’s color may help you identify the type of medication it is.
Example Question:
What color was the cough medicine?
Finding:
Reports taking one spoonful of cough medicine
(Available)
Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the dose of cough medicine allows you to determine whether it is being taken correctly.
Example Question:
How much medicine did you take?
Finding:
Reports mother gave him the medicine
(Found)
Pro Tip: Children should only take medication under the supervision of an adult who can assure it is taken as directed. You should ask younger patients whether the medicine was given to them and by whom.
Example Question:
Who gave you the medicine for your cough?
Finding:
Reports only took the medicine this morning
(Found)
Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the frequency Danny took cough medicine allows you to determine whether it is being taken correctly.
Example Question:
How many times have you taken the cough medicine?
Finding:
Denies home remedies
(Available)
Pro Tip: Patients sometimes try non-medicinal home remedies to treat coughs, such as breathing steam, or drinking tea with honey. Not all home remedies are effective or advisable, so it’s important to find out what remedies the patient has tried.
Example Question:
Have you tried any home remedies for your cough?
Finding:
Asked about typical medication use
Finding:
Denies taking medication
(Available)
Pro Tip: Knowing a patient’s current medication regimen helps you determine if any future treatments will be safe and effective.
Example Question:
Do you take any medications from a doctor?
Finding:
Reports taking daily vitamin
(Found)
Pro Tip: Some symptoms can occur as a result of a vitamin deficiency, and others as a result of vitamin excess. Vitamins can also interfere with some treatments, so it’s important to know what your patient is taking.
Example Question:
Do you take vitamins?
Finding:
Asked about activity level
Finding:
Reports typical high activity level
(Found)
Pro Tip: Establishing a patient’s typical activity level is an important baseline to help you determine how an illness is affecting his life.
Example Question:
Are you usually active?
Finding:
Reports activity level low since getting sick
(Available)
Pro Tip: Establishing a patient’s activity level, and whether it has been impacted since becoming ill, is an important baseline to help you determine how an illness is affecting his life.
Example Question:
Have you been less active since getting sick?
Finding:
Reports still able to run or play
(Available)
Pro Tip: Ability to remain active indicates that the patient’s breathing is not dangerously affected, and that the patient isn’t seriously fatigued.
Example Question:
Are you able to keep up when you play with your classmates?
Finding:
Reports focusing in class is difficult
(Available)
Pro Tip: Mental lethargy and difficulty concentrating are common symptoms when a patient is sick.
Example Question:
Are you able to focus in class?
Finding:
Asked about nasal symptoms
Finding:
Reports current runny nose
(Found)
Pro Tip: Asking your patient if his nose is running will allow you to determine the symptoms he is experiencing and possible triggers.
Example Question:
Do you currently have a runny nose?
Finding:
Denies sneezing
(Available)
Pro Tip: Asking your patient if he has been sneezing will allow you to determine the symptoms he is experiencing and possible triggers.
Example Question:
Have you been sneezing?
Finding:
Followed up on nasal discharge
Finding:
Reports nasal discharge is clear
(Found)
Pro Tip: The color of a patient’s nasal discharge can provide you key information as to the type of condition the patient has.
Example Question:
What color is your snot?
Finding:
Reports nasal discharge is thin
(Available)
Pro Tip: The consistency of a patient’s nasal discharge can provide you key information as to the type of condition the patient has.
Example Question:
What is the consistency of your nasal discharge?
Finding:
Asked about ear symptoms
Finding:
Denies ear pain
(Found)
Pro Tip: Ear pain is often coincident with coughs and sinus problems. Asking about them allows you to ascertain if Danny needs follow-up care for his ears.
Example Question:
Do you have any ear pain?
Finding:
Reports history of frequent ear infections
(Found)
Pro Tip: Asking about Danny’s history of ear infections allows you to ascertain his risk for current and future ear infections.
Example Question:
Have you ever had ear infections?
Finding:
Denies ear discharge
(Found)
Pro Tip: Asking Danny about ear discharge, which are often coincident with of ear infections, allows you to ascertain his risk for current and future ear infections.
Example Question:
Do you have any ear discharge?
Finding:
Denies hearing problems
(Available)
Pro Tip: Simply talking with the patient assesses his hearing; however, some types of hearing loss are only apparent in specific settings such as noisy environments. Asking the patient about hearing problems identifies conditions that may not be readily apparent.
Example Question:
Do you have any hearing problems?
Finding:
Asked about throat symptoms
Finding:
Reports sore throat
(Found)
Pro Tip: Sore throats are often coincident with coughs and sinus problems. Asking about them allows you to ascertain if Danny needs follow-up care for his throat.
Example Question:
Is your throat sore?
Finding:
Reports a little pain with swallowing
(Available)
Pro Tip: Pain when swallowing helps you understand how severe the patient’s sore throat is.
Example Question:
Does it hurt when you swallow?
Past Medical History
Finding:
Asked about relevant medical history
Finding:
Reports frequent runny noses
(Found)
Pro Tip: Asking how often Danny experiences runny noses like the one he has now may help you determine the source of the problem.
Example Question:
Do you get runny noses often?
Finding:
Reports past frequent coughs
(Available)
Pro Tip: A patient experiencing a cough should be asked about their history of coughs so you can determine whether their current condition fits into a recurring pattern.
Example Question:
Do you have coughs very often?
Finding:
Reports past pneumonia
(Found)
Pro Tip: Pneumonia is a serious medical condition that can be life-threatening if not managed appropriately. Regardless of the patient’s presenting illness, it is critical to identify current medical conditions in order to treat the patient appropriately. Specific questions should be asked about previous medical problems, even if the patient doesn’t notice current symptoms.
Example Question:
Have you had pneumonia?
Finding:
Denies asthma diagnosis
(Available)
Pro Tip: Asthma is a serious medical condition that can be life-threatening if not managed appropriately. Regardless of the patient’s presenting illness, it is critical to identify current medical conditions in order to treat the patient appropriately. Specific questions should be asked about previous medical problems, even if the patient doesn’t notice current symptoms.
Example Question:
Do you have asthma?
Finding:
Reports immunizations as current
(Available)
Pro Tip: A health assessment should include an evaluation of the patient’s immunization status in order to identify diseases to which the patient is vulnerable.
Example Question:
Do you have current immunizations?
Finding:
Asked about allergies
Finding:
Denies seasonal allergies
(Found)
Pro Tip: Seasonal allergies can cause symptoms like runny nose, cough, and discomfort. Asking Danny if he has seasonal allergies can help you to ascertain possible triggers for symptoms.
Example Question:
Do you have seasonal allergies?
Finding:
Denies food allergies
(Found)
Pro Tip: Knowing if your patient has food allergies is important and relevant medical history. Asking your patient about food allergies will allow you to most effectively treat him.
Example Question:
Do you have food allergies?
Finding:
Denies medication allergies
(Found)
Pro Tip: Knowing if your patient has allergies to medicine is important and relevant medical history. Asking your patient about medicine allergies will allow you to most effectively treat him.
Example Question:
Are you allergic to any medication?
Finding:
Asked relevant family history
Finding:
Reports father has history of asthma
(Found)
Pro Tip: Medical problems such as asthma that are present in a patient’s immediate family can represent increased risk factors to respiratory conditions such as the ones the patient currently has.
Example Question:
Do you have a family history of asthma?
Finding:
Denies family history of allergies
(Available)
Pro Tip: Medical problems such as allergies that are present in a patient’s immediate family can represent increased risk factors to respiratory conditions such as the ones the patient currently has.
Example Question:
Do you have a family history of allergies?
Review of Systems
Finding:
Asked about constitutional health
Finding:
Denies chills
(Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has chills will illustrate the way his symptoms manifest.
Example Question:
Do you have chills?
Finding:
Denies fever
(Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has a fever will illustrate the way his symptoms manifest.
Example Question:
Do you have a fever?
Finding:
Reports feeling somewhat fatigued
(Found)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has fatigue will illustrate the way his symptoms manifest.
Example Question:
Do you have fatigue?
Finding:
Denies night sweats
(Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has night sweats will illustrate the way his symptoms manifest.
Example Question:
Do you have night sweats?
Finding:
Reports cough makes it difficult to sleep
(Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has had difficulty sleeping will illustrate the way his symptoms manifest.
Example Question:
Have you been sleeping okay?
Finding:
Denies swelling
(Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has had swelling will illustrate the way his symptoms manifest.
Example Question:
Have you noticed any swelling?
Finding:
Asked about additional review of systems for HEENT
Finding:
Reports frequent colds
(Available)
Pro Tip: A patient such as Danny who is presenting with a cough and a runny nose may have a cold, so you should ask about his history of colds to determine whether this is part of a larger pattern.
Example Question:
Do you have unusually frequent colds?
Finding:
Denies headaches
(Available)
Pro Tip: Headaches are a common complaint that can be caused by a variety of benign conditions. However, headaches can be an indicator of serious underlying neurological conditions such as cerebral hemorrhage, meningitis, or brain tumors. They may also be a symptom of sinus infection.
Example Question:
Do you get headaches?
Finding:
Denies nosebleeds
(Found)
Pro Tip: When a patient presents with symptoms that are often seen with respiratory infections, you should ask about similar signs of respiratory infections such as nosebleeds.
Example Question:
Do you have nosebleeds?
Finding:
Denies vision difficulty
(Available)
Pro Tip: Eye or vision problems can lower one’s ability to function and can be a major safety risk.
Example Question:
Do you have any problems with your vision?
Finding:
Denies dizziness
(Available)
Pro Tip: Asking about dizziness helps you assess the risk for inner ear, neurological, or cardiovascular problems.
Example Question:
Do you have any dizziness?
Finding:
Denies watery eyes
(Available)
Pro Tip: Whether a patient has watery eyes may help you indicate the type of sinus problem he is experiencing.
Example Question:
Do you have watery eyes?
Finding:
Denies eye redness
(Available)
Pro Tip: Whether a patient has eye redness may help you indicate the type of sinus problem he is experiencing.
Example Question:
Do you have eye redness?
Finding:
Denies eye pain
(Available)
Pro Tip: Eye pain can lower one’s ability to function and can be a major safety risk.
Example Question:
Do you have any eye pain?
Finding:
Denies sinus pain
(Available)
Pro Tip: Patients with sinus problems such as a runny nose may be at greater risk for sinus pain.
Example Question:
Do you have any sinus pain?
Finding:
Asked about review of systems for respiratory
Finding:
Denies chest tightness
(Available)
Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest tightness is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort.
Example Question:
Do you have chest tightness?
Finding:
Denies chest pain
(Available)
Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest pain is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort.
Example Question:
Do you have any chest pain?
Finding:
Denies difficulty breathing
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Objective Data Collection: 15 of 15 (100%)
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
Lesion
Sclera (1/4 point)
White
Yellow tint
Redness
Conjunctiva (1/4 point)
Moist and pink
Dry appearance
Redness
Swelling
Conjunctival Discharge (1/4 point)
No discharge
Clear, watery discharge
Purulent discharge
Inspected nasal cavities
1 of 1 point
Color (1/4 point)
Pink
Red
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
Right: Auditory Canal Color (1/10 point)
Pink
Red
Pallor
Right: Tympanic Membrane Color (1/10 point)
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)
No discharge
Cerumen
Clear discharge
Bloody discharge
Purulent discharge
Left: Auditory Canal Color (1/10 point)
Pink
Red
Pallor
Left: Tympanic Membrane Color (1/10 point)
Pearly gray
Red
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
1 of 1 point
Oral Mucosa (1/5 point)
Moist and pink
Dry appearance
Redness
Tonsils (1/5 point)
No visible abnormal findings
Swelling
Redness
Throat Color (1/5 point)
Pink
Red
Throat 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
Barrel chest
Intercostal retraction while breathing
Excessive use of accessory muscles while breathing
Skin growths (freckles or moles)
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
1 of 1 point
Bronchophony (1/1 point)
Positive
Negative
Auscultated heart sounds
1 of 1 point
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
Measured diaphragmatic excursion
1 of 1 point
Range (1/1 point)
3-5 cm
Greater than 3-5 cm
Less than 3-5 cm
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
1 of 1 point
Head And Neck (1/3 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
Palpated chest expansion
1 of 1 point
Symmetry (1/1 point)
Equal bilaterally
Unequal bilaterally
Education & Empathy : 2 of 3 (66.7%)
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. | ||
| What brings you here today? | ||
| My music teacher Mr. Hillman sent me here because he said I look sick. I have been coughing a lot. . . and I feel kinda tired. | ||
| I am sorry to hear that | ||
| Thanks. | ||
| Model Statement: “I’m sorry you’ve not been feeling well these past few days. Being sick isn’t fun, especially when it affects lots of different parts of your body. Let’s talk about what’s been happening, and we’ll figure out how to make you better.” |
2 Family Medical History
Followed Up
| Description: Danny describes what he knows about his family’s health and indicates his distress over their various health issues. | ||
| Are you exposed to secondhand 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, and I don’t like that he is hurting himself. He could get sick. | ||
| Secondhand smoke exposure can be harmful to you | ||
| OK. | ||
| Model Statement: “Thank you for telling me about your family’s health. It’s completely understandable that you care for your family and don’t like hearing that their health isn’t perfect, especially with how your Papi smokes. You were really brave to tell us about that.” |
3 Vitamins
Not Followed Up
| Description: Danny describes taking vitamins and occasionally sneaking extras. | ||
| Do you take vitamins? | ||
| 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! | ||
| Do you play in school? (Clarified to: Do you do a lot of playing?) | ||
| I don’t play any sports on a team, but Tony and I play outside. We like to skateboard and shoot hoops. (Clarified to: if I do a lot of playing) | ||
| Any relevant family history? | ||
| 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.” |
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