Focused Exam Cough All Shadow Health PDF

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Summary

Focused exam cough Medical Surgery...

Description

4/1/2021

Focused Exam: Cough | Completed | Shadow Health

Focused Exam: Cough Results | Turned In Nursing 562/562L Advanced Health Assessment - Spring 2021, N562 Return to Assignment (/assignments/433800/)

Your Results

Overview

Lab Pass (/assignment_attempts/9552828/lab_pass.p

Experience Overview

Transcript Subjective Data Collection

Student Performance Index

Patient: Danny Rivera

38.15 out of 39

Objective Data Collection Education & Empathy Documentation Program Competency Progress

Proficiency Level: Proficient Beginning

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 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Developing

Proficient

Students rated as “proficient” demonstrate an entry-level expe in advanced practice competencies and clinical reasoning skills comparable programs, the top 25% of students perform at level of a proficient practitioner. Subjective Data Collection

Objective Data Collection

21 out of 21

12.15 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.

© Shadow Health ® 2012 - 2021 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (https://www.shadowhealth.com/patents)

https://app.shadowhealth.com/assignment_attempts/9552828

1/1

4/1/2021

Focused Exam: Cough | Completed | Shadow Health

Focused Exam: Cough Results | Turned In Nursing 562/562L Advanced Health Assessment - Spring 2021, N562 Return to Assignment (/assignments/433800/)

Your Results

Overview

Lab Pass (/assignment_attempts/9552828/lab_pass.p

Subjective Data Collection: 21 of 21 (100.0%)

Transcript Subjective Data Collection

Hover To Reveal...

Indicates an item that you found.

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

Indicates an item that is available to be found.

Objective Data Collection Education & Empathy Documentation Program Competency Progress

Category

Scored Items

Patient Data Not Scored

Experts selected these topics as essential components of a strong, thorough interview with this patient.

A combination of open and closed questions will yi better patient data. The following details are facts o the patient's case.

Chief Complaint

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

History of Present Illness

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

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Reports current runny nose

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4/1/2021

Focused Exam: Cough | Completed | Shadow Health Denies sneezing Reports frequent runny nose

Followed up on nasal discharge

Reports nasal discharge is clear Reports nasal discharge is thin

Asked about ear symptoms

Followed up on ear pain

Reports pain in right ear

Reports ear pain started yesterday Reports ear pain is a 3 out of 10 Denies ear discharge

Asked about throat symptoms

Reports sore throat Reports "a little" pain with swallowing

Asked about allergies

Denies seasonal allergies Denies food allergies Denies medication allergies Denies allergies to animals Denies latex allergy

Asked about contact with illnesses

Denies being around anyone ill at home

Home Medications

Asked about home medications

Confirmed home medications Reports taking a daily vitamin Reports taking cough medicine

Followed up on cough medicine

Reports cough medicine was purple Reports taking one spoonful of cough medicine Reports mother gave him the medicine Reports cough medicine provided temporary relief

Past Medical History

Asked about relevant medical history

Denies asthma diagnosis Reports immunizations as current Reports past pneumonia and frequent coughs Denies past hospitalizations

Social Determinants of Health

Asked about exposure to secondhand smoke

Reports father smokes cigars Reports father sometimes forgets to take cigars outside

Social History

Asked about living conditions

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Reports living in a house with parents and grandparents

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Focused Exam: Cough | Completed | Shadow Health Reports feeling safe at home Reports park with playground near home

Review of Systems

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.

© Shadow Health ® 2012 - 2021 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (https://www.shadowhealth.com/patents)

https://app.shadowhealth.com/assignment_attempts/9552828

3/3

4/1/2021

Focused Exam: Cough | Completed | Shadow Health

Focused Exam: Cough Results | Turned In Nursing 562/562L Advanced Health Assessment - Spring 2021, N562 Return to Assignment (/assignments/433800/)

Your Results

Overview

Lab Pass (/assignment_attempts/9552828/lab_pass.p

Objective Data Collection: 12.15 of 13 (93.46%)

Transcript Subjective Data Collection Objective Data Collection

Correct

Incorrect

Partially correct

Missed

Education & Empathy

Inspected eyes and orbital area

0.75 of 1 poin

Documentation Program Competency Progress

Orbital Area (1/4 point)

Sclera (No point)

No visible abnormal findings

White

Ptosis

Jaundice

Eyelid edema

Injection

Lesion

Icterus

Allergic shiners Conjunctiva (1/4 point)

Conjunctival Discharge (1/4 point)

Moist and pink

No discharge

Pale

Clear, watery discharge

Dry appearance

Purulent discharge

Erythema Edema

Inspected nasal cavities Color (1/4 point)

1 of 1 point

Discharge (1/4 point)

Pink

No discharge

Erythemic

Clear discharge

Bluish

Bloody discharge Purulent discharge

Turbinate Patency (1/4 point)

Observations (1/4 point)

Patent

No additional visible abnormal findings

Decreased patency

Foreign body present

Not patent

Polyp Septum perforated Septum deviated Lesion

Inspected ears Right: Auditory Canal Color (No point)

0.8 of 1 point

Right: Tympanic Membrane Color (No point)

Pink

Pearly gray

Erythemic

Erythemic

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4/1/2021

Focused Exam: Cough | Completed | Shadow Health Pallor

Opaque Yellow Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 point)

Right: Cone Of Light (1/10 point)

No visible abnormal findings

5:00

Fluid observed

Cone of light distorted

Visible scars Bulging Perforation Retraction Right: Discharge (1/10 point)

Left: Auditory Canal Color (1/10 point)

No discharge

Pink

Cerumen

Erythemic

Clear discharge

Pallor

Bloody discharge Purulent discharge Left: Tympanic Membrane Color (1/10 point)

Left: Tympanic Membrane Appearance (1/10 point)

Pearly gray

No visible abnormal findings

Erythemic

Fluid observed

Opaque

Visible scars

Yellow

Bulging

Not visible because of cerumen

Perforation Retraction

Left: Cone Of Light (1/10 point)

Left: Discharge (1/10 point)

7:00

No discharge

Cone of light distorted

Cerumen Clear discharge Bloody discharge Purulent discharge

Inspected mouth and throat Oral Mucosa (1/5 point)

0.6 of 1 point

Tonsils (No point)

Moist and pink

No visible abnormal findings

Dry appearance

Edema

Erythema

Erythema

Posterior Oropharynx Color (No point)

Posterior Oropharynx Texture (1/5 point)

Pink

No abnormal findings

Erythemic

Cobblestoning Exudate

Post Nasal Drip (1/5 point) No discharge Clear discharge Purulent discharge

Inspected neck Symmetry (1/2 point)

1 of 1 point

Appearance (1/2 point)

Symmetric

No visible abnormal findings

Asymmetric

Swelling Visible pulsation Visible mass Discoloration

Inspected chest Symmetry (1/2 point) Symmetric

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1 of 1 point

Appearance (1/2 point) No visible abnormal findings

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Focused Exam: Cough | Completed | Shadow Health 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 Frontal (1/2 point)

1 of 1 point

Maxillary (1/2 point)

None reported

None reported

Tenderness reported

Tenderness reported

Palpated lymph nodes Cervical (1/3 point)

1 of 1 point

Supraclavicular (1/3 point)

No palpable nodes

No palpable nodes

Palpable nodes on right side

Palpable nodes on right side

Palpable nodes on left 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 Symmetry (1/2 point)

1 of 1 point

Vibration (1/2 point)

Equal bilaterally

Expected fremitus

Unequal bilaterally

Decreased fremitus

Auscultated breath sounds

1 of 1 point

Breath Sounds (1/3 point)

Adventitious Sounds (1/3 point)

Present in all areas

No adventitious sounds

Diminished in some areas

Wheezing

Absent in some areas

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

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Focused Exam: Cough | Completed | Shadow Health

Auscultated heart sounds Heart Sounds (1/2 point)

1 of 1 point

Extra Heart Sounds (1/2 point)

S1 and S2 audible

No extra sounds

S1, S2, and S3 audible

Gallops

S1, S2, and S4 audible

Murmur

S1, S2, S3, and S4 audible

Friction rub Valve clicks

Percussed chest wall

1 of 1 point

Observations (1/2 point)

Location (1/2 point)

All areas resonant

No areas of dullness

Some areas dull, some resonant

Dullness, anterior right upper lobe

Some areas hyperresonant, some resonant

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.

© Shadow Health ® 2012 - 2021 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (https://www.shadowhealth.com/patents)

https://app.shadowhealth.com/assignment_attempts/9552828

4/4

4/1/2021

Focused Exam: Cough | Completed | Shadow Health

Focused Exam: Cough Results | Turned In Nursing 562/562L Advanced Health Assessment - Spring 2021, N562 Return to Assignment (/assignments/433800/)

Your Results

Overview

Lab Pass (/assignment_attempts/9552828/lab_pass.p

Education & Empathy : 5 of 5 (100.0%)

Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed bel are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of 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 w made Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient

Program Competency Progress

1 Symptoms

Followed Up

Description: Danny describes the symptoms that have been bothering him.

Have you been sneezing

Questio 06:10 PM MD

I don't usually have to sneeze. My nose gets runny a lot of times though, like I have a cold.

Does your chest hurt

Questio 06:10 PM MD

No, I don't have pain in my chest. I would hate that!

Do you have asthma

Questio 06:10 PM MD

Is that when you have to use a, uh, an inhaler? My friend Tony does that sometimes, but I don't have to.

That's good

Empathiz 06:11 PM MD

Thank you.

Model Statement: "I’m sorry your ear and your throat hurt. I’ll take a look and we’ll see if we can help you feel better."

2 Medications https://app.shadowhealth.com/assignment_attempts/9552828

Up

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4/1/2021

Focused Exam: Cough | Completed | Shadow Health Description: Danny describes the medication he was given for his cough.

Your mom gave you some cough medicine

Questio 05:50 PM MD

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

Questio 05:51 PM MD

She just gave me one spoonful of it.

Did the cough medicine help

Questio 05:51 PM MD

It helped a bit when my mom gave it to me, but my cough came back anyway.

I'm sorry to hear that

Empathiz 05:51 PM MD

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."

3 Vitamins

Followed Up

Description: Danny describes taking vitamins.

To take any vitamins or supplements

Questio 06:06 PM MD

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.

Educa 06:07 PM MD

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."

4 Secondhand Smoke

Followed Up

Description: Danny describes exposure to secondhand smoke at home.

Have you been around any people that smoke (Clarified to: Have you been around smokers?)

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Questio 05:49 PM MD

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4/1/2021

Focused Exam: Cough | Completed | Shadow Health Well . . . sometimes Papi ...