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Focused Exam Cough All Shadow Health
Medical Surgery 2 (NUR 2214)
Florida State College at Jacksonville
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Focused Exam: Cough Results | Turned In
Nursing 562/562L Advanced Health Assessment - Spring 2021, N
Return to Assignment (/assignments/433800/)
Experience Overview
Your Results Lab Pass (/assignment_attempts/9552828/lab_pass
Overview
Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Program Competency Progress
####### Patient: Danny Rivera
####### Digital Clinical Experience Score
100%
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%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.
####### Student Performance Index
38 out of 39
####### Proficiency Level: Proficient
Students rated as “proficient” demonstrate an entry-level exper in advanced practice competencies and clinical reasoning skills comparable programs, the top 25% of students perform at level of a proficient practitioner.
Beginning Developing Proficient
Subjective Data Collection
####### 21 out of 21
Objective Data Collection
####### 12 out of 13
Education and Empathy
####### 5 out of 5
####### Time
####### 110 minutes total spent in assignment
Interaction with patient
####### 110 minutes
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
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Focused Exam: Cough Results | Turned In
Nursing 562/562L Advanced Health Assessment - Spring 2021, N
Return to Assignment (/assignments/433800/)
Subjective Data Collection: 21 of 21 (100%)
Chief Complaint
History of Present Illness
Your Results Lab Pass (/assignment_attempts/9552828/lab_pass
Overview Transcript Subjective Data Collection
Objective Data Collection Education & Empathy Documentation Program Competency Progress
Indicates an item that you found. 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 yie better patient data. The following details are facts o the patient's case.
Established chief complaint Reports cough
Asked about onset of cough Reports cough started 5 days ago
Asked about frequency and duration of cough Reports coughing every few minutes
Asked about character of cough Reports cough is wet Reports clear sputum
Asked about aggravating factors for cough Reports cough is worse at night Reports exposure to secondhand smoke Denies knowing what makes the cough worse
Asked about relieving factors for cough Denies resting relieves cough Denies drinking water relieves cough
Asked about nasal symptoms Reports current runny nose
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Support
Review of Systems
Reports feeling safe at home Reports park with playground near home
Asked about constitutional health Denies fever Denies chills Reports feeling "kind of tired" Denies night sweats Denies weight loss Denies appetite loss
Asked about review of systems for HEENT Denies ear popping or crackling Reports history of frequent ear infections Denies ear surgery or ear tubes Denies headaches Denies nosebleeds Denies vision problems Denies dizziness Denies watery eyes Denies eye redness Denies eye pain Denies sinus pain Denies hearing problems
Asked about review of systems for respiratory Denies difficulty breathing Denies chest tightness Denies chest pain Denies history of inhaler use or breathing treatments
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
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Focused Exam: Cough Results | Turned In
Nursing 562/562L Advanced Health Assessment - Spring 2021, N
Return to Assignment (/assignments/433800/)
Objective Data Collection: 12 of 13 (93%)
Your Results Lab Pass (/assignment_attempts/9552828/lab_pass
Overview Transcript Subjective Data Collection Objective Data Collection
Education & Empathy Documentation Program Competency Progress
Correct Partially correct
Incorrect Missed
Inspected eyes and orbital area 0 of 1 point
Orbital Area (1/4 point) No visible abnormal findings Ptosis Eyelid edema Lesion Allergic shiners
Sclera (No 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 of 1 point
Right: Auditory Canal Color (No point) Pink Erythemic
Right: Tympanic Membrane Color (No point) Pearly gray Erythemic Support
Asymmetric 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 1 of 1 point
Cervical (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
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
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
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Description: Danny describes the medication he was given for his cough.
Your mom gave you some cough medicine 05:50 PM MD Questio
I don't know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON]
Do you know what dose of cough medicine she gave you 05:51 PM MD Questio
She just gave me one spoonful of it.
Did the cough medicine help 05:51 PM MD Questio
It helped a bit when my mom gave it to me, but my cough came back anyway.
I'm sorry to hear that 05:51 PM MD Empathiz
Thank you.
Make sure you're not taking cough medicine without your mom helping you. Its important to only take the correct dose.
Educat 05:52 PM MD
Oh, OK.
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."
Description: Danny describes taking vitamins.
To take any vitamins or supplements 06:06 PM MD Questio
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 should not take extra vitamins, that can be dangerous. Only take one a day. 06:07 PM MD Educat
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."
Description: Danny describes exposure to secondhand smoke at home.
Have you been around any people that smoke (Clarified to: Have you been around smokers?) 05:49 PM MD Questio
3 Vitamins Followed Up
4 Secondhand Smoke Followed Up
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. (Clarified to: if I have been around anyone that smokes)
That's good breathing secondhand smoke can be bad for you 05:49 PM MD Educat
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."
Description: Danny describes what he knows about his family health history.
Does anybody in your family have allergies 06:11 PM MD Questio
I don't think so, but I guess I'm not sure.
Make sure you're covering your cough 06:11 PM MD Educat
Oh, OK.
Model Statement: "Thanks for telling me what you know about your family history. You did a good job remembering."
5 Family History Followed Up
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
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####### Student Documentation Model Documentation
Plan Lab: Rapid strep test Educate patient and care giver on supportive therapies: warm saltwater gargles, soothing teas, and topical anesthetics for throat. Encourage rest adequate fluid intsake avoidence of secondhand smoke nad respiratory irritants. NSAIDS or acetaminophen in child appropriate doses may be used for pain and or fever. Instruct patient and caregiver to monitor for worsening symptoms, fever, respiritory distress and to seek immediate emergent care if needed. Schedule follow up in 1 week if symptoms do not improve.
Danny should be referred for an allergy test to rule out allergie well as a lung function test to rule out asthma. He should rece a strep culture to rule out strep throat. I recommend antitussiv treatment at night to help with his sleep in addition to bed rest
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
© Shadow Health 2012 - 2021 (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (shadowhealth/patents)
®
Focused Exam: Cough Results | Turned In
Nursing 562/562L Advanced Health Assessment - Spring 2021, N
Return to Assignment (/assignments/433800/)
Documentation / Electronic Health Record
Document: Vitals
Vitals
Blood Pressure 120/
O2 Sat 96% room air
Pulse 100
Resp. Rate 28
Temperature 37.
Your Results Lab Pass (/assignment_attempts/9552828/lab_pass
Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation
Program Competency Progress
Document: Vitals Document: Provider Notes
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
© Shadow Health 2012 - 2021 (800) 860-3241 | Help Desk (support.shadowhealth/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (shadowhealth/patents)
®
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Focused Exam Cough All Shadow Health
Course: Medical Surgery 2 (NUR 2214)
University: Florida State College at Jacksonville
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