Focused Exam: Cough, Danny Rivera Shadow health Transcript
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Hello. I amxxx, I will interview and examine you.
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Greet |
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Hi.
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What is your name?
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My name is Daniel Rivera, but I just go by Danny.
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What brings you to the clinic today?
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My Abuela brought me here because I’ve been feeling sick. I have been coughing a lot. . . and I feel kinda tired.
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Am sorry to hear that you are sick.
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Empathize |
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Thank you.
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Do you have a cough?
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I guess I’m kind of sick. . . I’ve been coughing a lot.
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How long have you had a cough?
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I think the cough started four. . . No, it started five days ago.
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Is your cough a wet or a dry one? Focused Exam: Cough, Danny Rivera Shadow health Transcript
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My cough seems kind of gurgly and watery.
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That sounds like a wet cough.
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Oh, OK.
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Do you produce any phlegm or sputum with your cough?
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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.
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Am sorry to hear that.
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Empathize |
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Thank you.
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How often is your cough?
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I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
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Is the cough keeping you up at night?
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I don’t usually wake up once I go to bed, but my cough has made it hard to fall asleep.
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Am sorry to hear this
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Empathize |
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Thank you.
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Do you smoke?
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No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don’t like how they smell.
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True smoking is bad for everyone, you should never smoke.
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Oh, OK.
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Are you ever around cigarette smoke?
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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.
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Am sorry to hear that I understand your concern.
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Empathize |
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Thank you.
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What makes your cough worse?
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My cough mostly stays the same no matter what I do. It seems to get worse at night though.
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Have you tried to treat your cough?
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I had some cough medicine this morning. [AUDIO COMING SOON]
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What is the name of the medicine?
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I don’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON]
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Who gave you the medicine?
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My mom.
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How much medicine did you take?
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I just had one spoonful of it.
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How many times have you taken the cough medicine?
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I only took the cough medicine once. My mom gave me a spoonful. [AUDIO COMING SOON]
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Do you take vitamins?
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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!
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I understand it’s good to take vitamins, but do not take more than the recommended dosage,
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Oh, OK.
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Are you usually active?
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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]
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Great, keep exercising.
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Educate |
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Oh, OK.
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Does the cough make you less active?
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No, that doesn’t help my cough.
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Are you able to focus in class?
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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]
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Am sorry to hear that.
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Empathize |
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Thank you.
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Do you have a runny nose?
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My nose is always a little bit runny… but ever since I started coughing it’s been worse, I think.
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Am sorry to hear that.
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Empathize |
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Thank you.
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Have you been sneezing?
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I don’t usually have to sneeze. My nose gets runny a lot of times though, like I have a cold.
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What color is your snot?
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You mean like when I blow my nose? It’s clear.
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Yes that one, Ok, thanks.
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Empathize |
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Thank you.
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How consistent is your nasal discharge?
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It’s kind of clear and, like, watery.
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Any ear pain?
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My right ear is starting to hurt a little bit . . . my left one is OK though.
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Sorry Danny.
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Empathize |
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Thank you.
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Any ear discharge?
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No, nothing comes out of my ears, but my right ear kind of hurts.
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Any hearing problems?
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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 . . .
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Good, its good to have a test done whenever there is a chance.
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Educate |
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Oh, OK.
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Any sore throat?
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It feels a little bit sore, yeah.
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Does it hurt when you swallow?
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No, I can swallow OK. It hurts a little right now because my throat is kinda sore.
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Have you had pneumonia?
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I think I had that last year, when I was seven. My mom was really worried.
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Have you had asthma?
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Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don’t have to.
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Yes that one. Ok
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Empathize |
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Thank you.
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Do you have current immunizations?
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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.
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Your mum is right Danny, immunization helps prevent diseases.
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Oh, OK.
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Do you have seasonal allergies?
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I don’t think I have any allergies like that.
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Do you have any food allergies?
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I’m not allergic to any foods I don’t think.
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Are you allergic to any medication?
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I don’t think I’m allergic to medicine.
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Any family history of asthma?
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Only Papi had asthma, I think.
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Any family history of allergies?
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I don’t think so, but I guess I’m not sure.
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Do you have chills?
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No, I haven’t felt that.
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Do you have fever?
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My mom said I didn’t have a fever this morning before Abuela took me here.
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Are you fatigued?
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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.
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Sorry about that.
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Empathize |
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Thank you.
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Do you have night sweats?
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I don’t sweat at night unless it gets really hot or something.
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Do you suffer from frequent colds?
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I get colds a lot. My nose is always runny.
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Do you get headaches?
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I don’t usually get headaches.
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in anterior left lower lobe
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in posterior left upper lobe
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Auscultated voice sounds in posterior right upper lobe
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Ninety-nine.
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Auscultated voice sounds in posterior left mid-back (lower lobe)
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Ninety-nine.
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Auscultated voice sounds in posterior right mid-back (lower lobe)
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Ninety-nine.
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Auscultated voice sounds in posterior left lower lobe near spine
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Ninety-nine.
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Auscultated voice sounds in posterior right lower lobe near spine
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in posterior left lower lobe on side
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Exam Action |
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Ninety-nine.
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Auscultated voice sounds in posterior left lower lobe
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in posterior right lower lobe
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Exam Action |
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Ninety-nine.
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Auscultated voice sounds in posterior right lower lobe on side Focused Exam: Cough, Danny Rivera Shadow health Transcript
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Ninety-nine.
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Ninety-nine.
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Auscultated aortic area with the bell
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Auscultated pulmonic area with the bell
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Auscultated Erb’s point with the bell
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Auscultated tricuspid area with the bell
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Auscultated mitral area with the bell
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Auscultated mitral area with the diaphragm
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Auscultated aortic area with the diaphragm
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Auscultated pulmonic area with the diaphragm
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Auscultated Erb’s point with the diaphragm
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Auscultated tricuspid area with the diaphragm
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Auscultated mitral area with the diaphragm
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Percussed anterior right upper lobe
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Percussed anterior left upper lobe
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Percussed anterior right middle lobe
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Percussed anterior left mid-chest (upper lobe)
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Percussed anterior right lower lobe
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Percussed anterior left lower lobe
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Percussed posterior left upper lobe
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Percussed posterior right upper lobe
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Percussed posterior left mid-back (lower lobe)
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Percussed posterior right mid-back (lower lobe)
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Percussed posterior left lower lobe
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Percussed posterior right lower lobe
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Percussed posterior left lower lobe on side
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Percussed posterior left lower lobe near spine
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Percussed posterior right lower lobe near spine
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