Focused Exam: Cough, Danny Rivera Shadow health Transcript

Focused Exam: Cough, Danny Rivera Shadow health Transcript

Patient Examination: Cough, Danny Rivera – Shadow Health Transcript
Greetings
April 1, 2023, 8:27 AM EDT
Danny Rivera
Hi there.

Healthcare Provider
What is your name?

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Question
April 1, 2023, 8:36 AM EDT
Danny Rivera
My name is Daniel Rivera, but I go by Danny.

Healthcare Provider
What brings you to the clinic today?

Building a Health History Discussion Case – Adolescent white male without health insurance seeking medical care for STI

Question
April 1, 2023, 8:36 AM EDT
Danny Rivera
I’m here because my grandmother brought me. I’ve been feeling unwell, coughing a lot, and feeling tired.

Healthcare Provider
I’m sorry to hear that you’re not feeling well.

Empathize
April 1, 2023, 8:37 AM EDT
Danny Rivera
Thank you.

Healthcare Provider
Do you have a cough?

Question
April 1, 2023, 8:37 AM EDT
Danny Rivera
I think I’m sick. I’ve been coughing a lot.

Healthcare Provider
How long have you had the cough?

Question
April 1, 2023, 8:38 AM EDT
Danny Rivera
I believe the cough started five days ago.

Healthcare Provider
Is your cough productive (wet) or dry?

Question
April 1, 2023, 8:40 AM EDT
Danny Rivera
My cough seems gurgly and watery.

Healthcare Provider
That sounds like a wet cough.

Educate
April 1, 2023, 8:41 AM EDT
Danny Rivera
Okay.

Healthcare Provider
Are you producing any phlegm with your cough?

Question
April 1, 2023, 8:42 AM EDT
Danny Rivera
You mean that slimy stuff? Yes, I’ve been coughing some of that up, but it’s clear.

Healthcare Provider
I’m sorry to hear that.

Empathize
April 1, 2023, 8:43 AM EDT
Danny Rivera
Thank you.

Healthcare Provider
How often do you cough?

Question
April 1, 2023, 8:43 AM EDT
Danny Rivera
I feel the need to cough every few minutes, and it seems to get worse at night.

Healthcare Provider
Is the cough affecting your sleep?

Question
April 1, 2023, 8:43 AM EDT
Danny Rivera
I usually don’t wake up once I go to bed, but my cough has made it hard to fall asleep.

Healthcare Provider
I’m sorry to hear this.

Empathize
April 1, 2023, 8:44 AM EDT
Danny Rivera
Thank you.

Healthcare Provider
Do you smoke?

Question
April 1, 2023, 8:44 AM EDT
Danny Rivera
No, I don’t. I know smoking is bad, even for adults. My dad smokes cigars sometimes, but I don’t like how they smell.

Healthcare Provider
You’re right; smoking is harmful to health. It’s good that you don’t smoke.

Educate
April 1, 2023, 8:44 AM EDT
Danny Rivera
Okay.

Healthcare Provider
Are you exposed to cigarette smoke at home?

Question
April 1, 2023, 8:46 AM EDT
Danny Rivera
Sometimes my dad smokes cigars in the house, and my mom has to ask him to go outside. I do breathe it a little then, but it’s not all the time. I don’t like how it smells.

Healthcare Provider
I understand your concern. It’s good that your mom asks him to smoke outside.

Empathize
April 1, 2023, 8:46 AM EDT
Danny Rivera
Thank you.

Healthcare Provider
What worsens your cough?

Question
April 1, 2023, 8:47 AM EDT
Danny Rivera
My cough mostly stays the same no matter what I do, but it seems to get worse at night.

Healthcare Provider
Have you tried any treatment for your cough?

Question
April 1, 2023, 8:47 AM EDT
Danny Rivera
I took some cough medicine this morning.

Healthcare Provider
What’s the name of the medicine?

Question
April 1, 2023, 8:47 AM EDT
Danny Rivera
I don’t know the name; it was purple.

Healthcare Provider
Who gave you the medicine?

Question
April 1, 2023, 8:47 AM EDT
Danny Rivera
My mom.

Healthcare Provider
How much medicine did you take?

Question
April 1, 2023, 8:49 AM EDT
Danny Rivera
I had one spoonful of it.

Healthcare Provider
How many times have you taken the cough medicine?

Question
April 1, 2023, 8:49 AM EDT
Danny Rivera
I only took it once. My mom gave me a spoonful.

Healthcare Provider
Do you take vitamins?

Question
April 1, 2023, 8:49 AM EDT
Danny Rivera
Yes, I take gummy dinosaur vitamins every day. Sometimes I sneak extra ones to be super healthy.

Healthcare Provider
It’s good to take vitamins, but be careful not to take more than the recommended amount.

Educate
April 1, 2023, 8:51 AM EDT
Danny Rivera
Okay.

Healthcare Provider
Are you usually active?

Question
April 1, 2023, 8:51 AM EDT
Danny Rivera
I have gym class every day, and I play at the park near my house after school or on weekends if the weather is nice.

Healthcare Provider
That’s great! Keep being active.

Educate
April 1, 2023, 8:51 AM EDT
Danny Rivera
Okay.

Healthcare Provider
Does the cough make you less active?

Question
April 1, 2023, 8:51 AM EDT
Danny Rivera
No, it doesn’t affect my activity level.

Healthcare Provider
Are you able to focus in class?

Question
April 1, 2023, 8:52 AM EDT
Danny Rivera
I can usually focus, but last night, I couldn’t sleep well because of my cough, so it was harder than normal to pay attention.

Healthcare Provider
I’m sorry to hear that.

Empathize
April 1, 2023, 8:52 AM EDT
Danny Rivera
Thank you.

Healthcare Provider
Do you have a runny nose?

Question
April 1, 2023, 8:52 AM EDT
Danny Rivera
My nose is always a bit runny, but it’s been worse since I started coughing.

Healthcare Provider
I’m sorry to hear that.

Empathize
April 1, 2023, 8:52 AM EDT
Danny Rivera
Thank you.

Healthcare Provider
Have you been sneezing?

Question
April 1, 2023, 8:53 AM EDT
Danny Rivera
I don’t usually sneeze. My nose just gets runny like I have a cold.

Healthcare Provider
What color is your nasal discharge?

Question

April 1, 2023, 8:53 AM EDT
Danny Rivera
When I blow my nose, it’s clear.

Healthcare Provider
Okay, thanks for letting me know.

Empathize
April 1, 2023, 8:53 AM EDT
Danny Rivera
Thank you.

Healthcare Provider
How consistent is your nasal discharge?

Question
April 1, 2023, 8:54 AM EDT
Danny Rivera
It’s clear and watery.

Healthcare Provider
Any ear pain?

Question
April 1, 2023, 8:54 AM EDT
Danny Rivera
My right ear hurts a little, but my left one is okay.

Healthcare Provider
I’m sorry to hear that your right ear hurts.

Empathize
April 1, 2023, 8:54 AM EDT
Danny Rivera
Thank you.

Healthcare Provider
Any ear discharge?

Question
April 1, 2023, 8:54 AM EDT
Danny Rivera
No, nothing comes out of my ears, but my right ear kind of hurts.

Healthcare Provider
Any hearing problems?

Question
April 1, 2023, 8:55 AM EDT
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.

Healthcare Provider
It’s good to have those tests done when given the opportunity.

Educate
April 1, 2023, 8:55 AM EDT
Danny Rivera
Okay.

Healthcare Provider
Do you have a sore throat?

Question
April 1, 2023, 8:55 AM EDT
Danny Rivera
My throat feels a bit sore.

Healthcare Provider
Does it hurt when you swallow?

Question
April 1, 2023, 8:56 AM EDT
Danny Rivera
No, I can swallow okay. It’s just a little sore right now because of my cough.

Healthcare Provider
Have you ever had pneumonia?

Question
April 1, 2023, 8:56 AM EDT
Danny Rivera
I think I had it last year when I was seven. My mom was really worried.

Healthcare Provider
Have you had asthma?

Question
April 1, 2023, 8:56 AM EDT
Danny Rivera
Is that when you have to use an inhaler? My friend Tony does that sometimes, but I don’t have to.

Healthcare Provider
Yes, that’s right. It’s good that you don’t need an inhaler.

Empathize
April 1, 2023, 8:56 AM EDT
Danny Rivera
Thank you.

Healthcare Provider
Do you have up-to-date immunizations?

Question
April 1, 2023, 8:57 AM EDT
Danny Rivera
I get shots whenever I visit the doctor. My mom says I need them for school, but I don’t like it.

Healthcare Provider
Your mom is right; immunizations help prevent diseases.

Educate
April 1, 2023, 8:59 AM EDT
Danny Rivera
Okay.

Healthcare Provider
Do you have seasonal allergies?

Question
April 1, 2023, 8:59 AM EDT
Danny Rivera
I don’t think I have any allergies like that.

Healthcare Provider
Do you have any food allergies?

Question
April 1, 2023, 8:59 AM EDT
Danny Rivera
I’m not allergic to any foods, I don’t think.

Healthcare Provider
Are you allergic to any medication?

Question
April 1, 2023, 9:00 AM EDT
Danny Rivera
I don’t think I’m allergic to medication.

Healthcare Provider
Is there a family history of asthma?

Question
April 1, 2023, 9:00 AM EDT
Danny Rivera
Only my dad had asthma, I think.

Healthcare Provider
Is there a family history of allergies?

Question
April 1, 2023, 9:00 AM EDT
Danny Rivera
I’m not sure about that.

Healthcare Provider
Do you have chills?

Question
April 1, 2023, 9:01 AM EDT
Danny Rivera
No, I haven’t experienced chills.

Healthcare Provider
Do you have a fever?

Question
April 1, 2023, 9:01 AM EDT
Danny Rivera
My mom said I didn’t have a fever this morning before my grandmother brought me here.

Healthcare Provider
Are you feeling fatigued?

Question
April 1, 2023, 9:01 AM EDT
Danny Rivera
Yes, I feel tired. I think it’s because I couldn’t sleep well at night due to my cough.

Healthcare Provider
I’m sorry about that.

Empathize
April 1, 2023, 9:01 AM EDT
Danny Rivera
Thank you.

Healthcare Provider
Do you have night sweats?

Question
April 1, 2023, 9:02 AM EDT
Danny Rivera
I don’t sweat at night unless it gets really hot.

Healthcare Provider
Do you frequently get colds?

Question
April 1, 2023, 9:02 AM EDT
Danny Rivera
I get colds often, and my nose is always runny.

Healthcare Provider
Do you experience headaches?

Question
April 1, 2023, 9:02 AM EDT
Danny Rivera
I usually don’t get headaches.

Patient Examination
April 1, 2023, 9:27 AM EDT
Auscultated voice sounds in various lung areas.

Patient Examination
April 1, 2023, 9:28 AM EDT
Auscultated voice sounds in various lung areas.

Patient Examination
April 1, 2023, 9:29 AM EDT
Auscultated voice sounds in heart areas.

Patient Examination
April 1, 2023, 9:29 AM EDT
Percussed various chest and lung areas.

Focused Exam: Cough, Danny Rivera Shadow health Transcript

Hello. I amxxx, I will interview and examine you.	Greet 04/01/23 8:27 AM EDT
	Hi.
	What is your name?	Question 04/01/23 8:36 AM EDT
	My name is Daniel Rivera, but I just go by Danny.
	What brings you to the clinic today?	Question 04/01/23 8:36 AM EDT
	My Abuela brought me here because I’ve been feeling sick. I have been coughing a lot. . . and I feel kinda tired.
	Am sorry to hear that you are sick.	Empathize 04/01/23 8:37 AM EDT
	Thank you.
	Do you have a cough?	Question 04/01/23 8:37 AM EDT
	I guess I’m kind of sick. . . I’ve been coughing a lot.
	How long have you had a cough?	Question 04/01/23 8:38 AM EDT
	I think the cough started four. . . No, it started five days ago.
	Is your cough a wet or a dry one? Focused Exam: Cough, Danny Rivera Shadow health Transcript	Question 04/01/23 8:40 AM EDT
	My cough seems kind of gurgly and watery.
	That sounds like a wet cough.	Educate 04/01/23 8:41 AM EDT
	Oh, OK.
	Do you produce any phlegm or sputum with your cough?	Question 04/01/23 8:42 AM EDT
	Is that the gross, slimy stuff? Yeah, I’ve been coughing some of that up. It’s not any strange color, though. It’s just clear.
	Am sorry to hear that.	Empathize 04/01/23 8:43 AM EDT
	Thank you.
	How often is your cough?	Question 04/01/23 8:43 AM EDT
	I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
	Is the cough keeping you up at night?	Question 04/01/23 8:43 AM EDT
	I don’t usually wake up once I go to bed, but my cough has made it hard to fall asleep.
	Am sorry to hear this	Empathize 04/01/23 8:44 AM EDT
	Thank you.
	Do you smoke?	Question 04/01/23 8:44 AM EDT
	No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell.
	True smoking is bad for everyone, you should never smoke.	Educate 04/01/23 8:44 AM EDT
	Oh, OK.
	Are you ever around cigarette smoke?	Question 04/01/23 8:46 AM EDT
	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.
	Am sorry to hear that I understand your concern.	Empathize 04/01/23 8:46 AM EDT
	Thank you.
	What makes your cough worse?	Question 04/01/23 8:47 AM EDT
	My cough mostly stays the same no matter what I do. It seems to get worse at night though.
	Have you tried to treat your cough?	Question 04/01/23 8:47 AM EDT
	I had some cough medicine this morning. [AUDIO COMING SOON]
	What is the name of the medicine?	Question 04/01/23 8:47 AM EDT
	I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON]
	Who gave you the medicine?	Question 04/01/23 8:47 AM EDT
	My mom.
	How much medicine did you take?	Question 04/01/23 8:49 AM EDT
	I just had one spoonful of it.
	How many times have you taken the cough medicine?	Question 04/01/23 8:49 AM EDT
	I only took the cough medicine once. My mom gave me a spoonful. [AUDIO COMING SOON]
	Do you take vitamins?	Question 04/01/23 8:49 AM EDT
	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!
	I understand it’s good to take vitamins, but do not take more than the recommended dosage,	Educate 04/01/23 8:51 AM EDT
	Oh, OK.
	Are you usually active?	Question 04/01/23 8:51 AM EDT
	I have gym class every day. I do all my exercises there. And there’s a park right next to my house where I play after school, or sometimes on the weekends, if it’s nice outside. [AUDIO COMING SOON]
	Great, keep exercising.	Educate 04/01/23 8:51 AM EDT
	Oh, OK.
	Does the cough make you less active?	Question 04/01/23 8:51 AM EDT
	No, that doesn’t help my cough.
	Are you able to focus in class?	Question 04/01/23 8:52 AM EDT
	I can focus normally, but I couldn’t sleep very well last night because of my coughing, so it was harder than normal. Plus, it’s harder to pay attention when you keep having to cough. [AUDIO COMING SOON]
	Am sorry to hear that.	Empathize 04/01/23 8:52 AM EDT
	Thank you.
	Do you have a runny nose?	Question 04/01/23 8:52 AM EDT
	My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
	Am sorry to hear that.	Empathize 04/01/23 8:52 AM EDT
	Thank you.
	Have you been sneezing?	Question 04/01/23 8:53 AM EDT
	I don’t usually have to sneeze. My nose gets runny a lot of times though, like I have a cold.
	What color is your snot?	Question 04/01/23 8:53 AM EDT
	You mean like when I blow my nose? It’s clear.
	Yes that one, Ok, thanks.	Empathize 04/01/23 8:53 AM EDT
	Thank you.
	How consistent is your nasal discharge?	Question 04/01/23 8:54 AM EDT
	It’s kind of clear and, like, watery.
	Any ear pain?	Question 04/01/23 8:54 AM EDT
	My right ear is starting to hurt a little bit . . . my left one is OK though.
	Sorry Danny.	Empathize 04/01/23 8:54 AM EDT
	Thank you.
	Any ear discharge?	Question 04/01/23 8:54 AM EDT
	No, nothing comes out of my ears, but my right ear kind of hurts.
	Any hearing problems?	Question 04/01/23 8:55 AM EDT
	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 . . .
	Good, its good to have a test done whenever there is a chance.	Educate 04/01/23 8:55 AM EDT
	Oh, OK.
	Any sore throat?	Question 04/01/23 8:55 AM EDT
	It feels a little bit sore, yeah.
	Does it hurt when you swallow?	Question 04/01/23 8:56 AM EDT
	No, I can swallow OK. It hurts a little right now because my throat is kinda sore.
	Have you had pneumonia?	Question 04/01/23 8:56 AM EDT
	I think I had that last year, when I was seven. My mom was really worried.
	Have you had asthma?	Question 04/01/23 8:56 AM EDT
	Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don’t have to.
	Yes that one. Ok	Empathize 04/01/23 8:56 AM EDT
	Thank you.
	Do you have current immunizations?	Question 04/01/23 8:57 AM EDT
	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.
	Your mum is right Danny, immunization helps prevent diseases.	Educate 04/01/23 8:59 AM EDT
	Oh, OK.
	Do you have seasonal allergies?	Question 04/01/23 8:59 AM EDT
	I don’t think I have any allergies like that.
	Do you have any food allergies?	Question 04/01/23 8:59 AM EDT
	I’m not allergic to any foods I don’t think.
	Are you allergic to any medication?	Question 04/01/23 9:00 AM EDT
	I don’t think I’m allergic to medicine.
	Any family history of asthma?	Question 04/01/23 9:00 AM EDT
	Only Papi had asthma, I think.
	Any family history of allergies?	Question 04/01/23 9:00 AM EDT
	I don’t think so, but I guess I’m not sure.
	Do you have chills?	Question 04/01/23 9:01 AM EDT
	No, I haven’t felt that.
	Do you have fever?	Question 04/01/23 9:01 AM EDT
	My mom said I didn’t have a fever this morning before Abuela took me here.
	Are you fatigued?	Question 04/01/23 9:01 AM EDT
	Yeah, I feel kind of tired. I think it’s because I couldn’t sleep much at night. My cough kept me from falling asleep.
	Sorry about that.	Empathize 04/01/23 9:01 AM EDT
	Thank you.
	Do you have night sweats?	Question 04/01/23 9:02 AM EDT
	I don’t sweat at night unless it gets really hot or something.
	Do you suffer from frequent colds?	Question 04/01/23 9:02 AM EDT
	I get colds a lot. My nose is always runny.
	Do you get headaches?	Question 04/01/23 9:02 AM EDT
	I don’t usually get headaches.

Ninety-nine.
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in anterior left lower lobe	Exam Action 04/01/23 9:27 AM EDT
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in posterior left upper lobe	Exam Action 04/01/23 9:28 AM EDT
	Auscultated voice sounds in posterior right upper lobe	Exam Action 04/01/23 9:28 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior left mid-back (lower lobe)	Exam Action 04/01/23 9:28 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior right mid-back (lower lobe)	Exam Action 04/01/23 9:28 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior left lower lobe near spine	Exam Action 04/01/23 9:28 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior right lower lobe near spine	Exam Action 04/01/23 9:28 AM EDT
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in posterior left lower lobe on side	Exam Action 04/01/23 9:28 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior left lower lobe	Exam Action 04/01/23 9:28 AM EDT
	Ninety-nine.
	Ninety-nine.
	Auscultated voice sounds in posterior right lower lobe	Exam Action 04/01/23 9:28 AM EDT
	Ninety-nine.
	Auscultated voice sounds in posterior right lower lobe on side Focused Exam: Cough, Danny Rivera Shadow health Transcript	Exam Action 04/01/23 9:28 AM EDT
	Ninety-nine.
	Ninety-nine.
	Auscultated aortic area with the bell	Exam Action 04/01/23 9:28 AM EDT
	Auscultated pulmonic area with the bell	Exam Action 04/01/23 9:28 AM EDT
	Auscultated Erb’s point with the bell	Exam Action 04/01/23 9:29 AM EDT
	Auscultated tricuspid area with the bell	Exam Action 04/01/23 9:29 AM EDT
	Auscultated mitral area with the bell	Exam Action 04/01/23 9:29 AM EDT
	Auscultated mitral area with the diaphragm	Exam Action 04/01/23 9:29 AM EDT
	Auscultated aortic area with the diaphragm	Exam Action 04/01/23 9:29 AM EDT
	Auscultated pulmonic area with the diaphragm	Exam Action 04/01/23 9:29 AM EDT
	Auscultated Erb’s point with the diaphragm	Exam Action 04/01/23 9:29 AM EDT
	Auscultated tricuspid area with the diaphragm	Exam Action 04/01/23 9:29 AM EDT
	Auscultated mitral area with the diaphragm	Exam Action 04/01/23 9:29 AM EDT
	Percussed anterior right upper lobe	Exam Action 04/01/23 9:29 AM EDT
	Percussed anterior left upper lobe	Exam Action 04/01/23 9:29 AM EDT
	Percussed anterior right middle lobe	Exam Action 04/01/23 9:29 AM EDT
	Percussed anterior left mid-chest (upper lobe)	Exam Action 04/01/23 9:29 AM EDT
	Percussed anterior right lower lobe	Exam Action 04/01/23 9:29 AM EDT
	Percussed anterior left lower lobe	Exam Action 04/01/23 9:30 AM EDT
	Percussed posterior left upper lobe	Exam Action 04/01/23 9:30 AM EDT
	Percussed posterior right upper lobe	Exam Action 04/01/23 9:30 AM EDT
	Percussed posterior left mid-back (lower lobe)	Exam Action 04/01/23 9:30 AM EDT
	Percussed posterior right mid-back (lower lobe)	Exam Action 04/01/23 9:30 AM EDT
	Percussed posterior left lower lobe	Exam Action 04/01/23 9:30 AM EDT
	Percussed posterior right lower lobe	Exam Action 04/01/23 9:30 AM EDT
	Percussed posterior left lower lobe on side	Exam Action 04/01/23 9:30 AM EDT
	Percussed posterior left lower lobe near spine	Exam Action 04/01/23 9:30 AM EDT
	Percussed posterior right lower lobe near spine	Exam Action 04/01/23 9:30 AM EDT Dont wait until the last minute. Provide your requirements and let our native nursing writers deliver your assignments ASAP. Start My Order