Focused Exam: Cough, Danny Rivera Shadow health Transcript
Hey there, I’m xxx, and I’ll be talking with you and checking how you’re feeling today.
Greeting
April 1st, 2023, 8:27 AM Eastern Time
Hey.
What’s your name?
Asking
April 1st, 2023, 8:36 AM Eastern Time
I’m Daniel Rivera, but folks usually call me Danny.
What brings you here today?
Asking
April 1st, 2023, 8:36 AM Eastern Time
My grandma brought me here because I’ve been feeling sick. I’ve been coughing a lot and feeling pretty tired.
I’m sorry to hear that you’re not feeling well.
Expressing Sympathy
April 1st, 2023, 8:37 AM Eastern Time
Thanks.
Do you have a cough?
Asking
April 1st, 2023, 8:37 AM Eastern Time
Yeah, I’m feeling kinda sick. I’ve been coughing quite a bit.
How long have you had this cough?
Asking
April 1st, 2023, 8:38 AM Eastern Time
I think it started about five days ago, not four.
Is your cough wet or dry?
Asking
April 1st, 2023, 8:40 AM Eastern Time
It’s kind of gurgly and watery.
Sounds like a wet cough.
Informing
April 1st, 2023, 8:41 AM Eastern Time
Got it.
Are you bringing up any phlegm or sputum when you cough?
Asking
April 1st, 2023, 8:42 AM Eastern Time
You mean that gross, slimy stuff? Yeah, I’ve been coughing some of that up. It’s clear though, not weird colors.
I’m sorry to hear that.
Expressing Sympathy
April 1st, 2023, 8:43 AM Eastern Time
Thanks.
How often are you coughing?
Asking
April 1st, 2023, 8:43 AM Eastern Time
Feels like I gotta cough every few minutes or so. Seems worse at night.
Is the cough disrupting your sleep?
Asking
April 1st, 2023, 8:43 AM Eastern Time
I usually sleep through the night once I’m out, but it’s been tough to fall asleep with all the coughing.
I’m sorry to hear that.
Expressing Sympathy
April 1st, 2023, 8:44 AM Eastern Time
Thanks.
Do you smoke?
Asking
April 1st, 2023, 8:44 AM Eastern Time
Nah, not me. I know smoking’s bad – even grown-ups say so. My dad smokes cigars sometimes, but I don’t like the smell.
Yeah, smoking’s harmful for everyone. Best to steer clear.
Educating
April 1st, 2023, 8:44 AM Eastern Time
Gotcha.
Do you ever find yourself around cigarette smoke?
Asking
April 1st, 2023, 8:46 AM Eastern Time
Yeah, sometimes my dad lights up inside, and then my mom tells him to go out. I end up breathing it in a bit, but not all the time. Still don’t like the smell, though.
I understand, it’s not pleasant.
Expressing Sympathy
April 1st, 2023, 8:46 AM Eastern Time
Thanks.
What seems to worsen your cough?
Asking
April 1st, 2023, 8:47 AM Eastern Time
My cough’s pretty steady no matter what. Gets worse at night, though.
Have you tried any remedies for your cough?
Asking
April 1st, 2023, 8:47 AM Eastern Time
Had some cough medicine this morning. [AUDIO COMING SOON]
What’s the name of the medicine?
Asking
April 1st, 2023, 8:47 AM Eastern Time
Not sure what it’s called. It was purple. [AUDIO COMING SOON]
Who gave you the medicine?
Asking
April 1st, 2023, 8:47 AM Eastern Time
My mom.
How much did you take?
Asking
April 1st, 2023, 8:49 AM Eastern Time
Just a spoonful.
How many times have you taken it?
Asking
April 1st, 2023, 8:49 AM Eastern Time
Only once. Mom gave me a spoonful. [AUDIO COMING SOON]
Do you take any vitamins?
Asking
April 1st, 2023, 8:49 AM Eastern Time
Yeah, I take gummy dinosaur vitamins every day. Sometimes sneak an extra one for good measure!
It’s good to take vitamins, but don’t overdo it.
Educating
April 1st, 2023, 8:51 AM Eastern Time
Got it.
Are you usually active?
Asking
April 1st, 2023, 8:51 AM Eastern Time
I have gym class every day and play at the park by my house after school or on weekends if it’s nice out. [AUDIO COMING SOON]
That’s great, keep up the activity.
Encouraging
April 1st, 2023, 8:51 AM Eastern Time
Will do.
Does your cough affect your activity level?
Asking
April 1st, 2023, 8:51 AM Eastern Time
Not really, but it sure doesn’t help.
Can you concentrate in class?
Asking
April 1st, 2023, 8:52 AM Eastern Time
Usually, yeah, but last night was rough with all the coughing. Hard to focus when you can’t stop coughing.
Sorry to hear that.
Expressing Sympathy
April 1st, 2023, 8:52 AM Eastern Time
Thanks.
Do you have a runny nose?
Asking
April 1st, 2023, 8:52 AM Eastern Time
It’s been kinda runny, especially since the cough started.
Sorry to hear that.
Expressing Sympathy
April 1st, 2023, 8:52 AM Eastern Time
Thanks.
Do you experience sneezing?
Asking
April 1st, 2023, 8:53 AM Eastern Time
Not much sneezing, but my nose feels like I have a cold sometimes.
What color is your mucus?
Asking
April 1st, 2023, 8:53 AM Eastern Time
When I blow my nose, it’s clear.
Got it, thanks.
Expressing Sympathy
April 1st, 2023, 8:53 AM Eastern Time
Thanks.
How consistent is your nasal discharge?
Asking
April 1st, 2023, 8:54 AM Eastern Time
It’s clear and watery.
Any ear pain?
Asking
April 1st, 2023, 8:54 AM Eastern Time
My right ear’s starting to hurt a bit,
but the left one’s fine.
Sorry to hear that, Danny.
Expressing Sympathy
April 1st, 2023, 8:54 AM Eastern Time
Thanks.
Do you notice any ear discharge?
Asking
April 1st, 2023, 8:54 AM Eastern Time
No, nothing coming out, but the right one’s bothering me.
Any hearing issues?
Asking
April 1st, 2023, 8:55 AM Eastern Time
We had a hearing test at school once. Thought maybe I’d have super hearing, but I’m just regular.
That’s good, testing is important.
Educating
April 1st, 2023, 8:55 AM Eastern Time
Got it.
Do you have a sore throat?
Asking
April 1st, 2023, 8:55 AM Eastern Time
It’s a bit sore.
Does it hurt when you swallow?
Asking
April 1st, 2023, 8:56 AM Eastern Time
I can swallow fine, just feels sore.
Have you ever had pneumonia?
Asking
April 1st, 2023, 8:56 AM Eastern Time
Think I had it last year when I was seven. Mom was really worried.
Have you been diagnosed with asthma?
Asking
April 1st, 2023, 8:56 AM Eastern Time
Is that when you use an inhaler? My friend Tony does, but I don’t need to.
Yep, that’s the one.
Expressing Sympathy
April 1st, 2023, 8:56 AM Eastern Time
Thanks.
Are your vaccinations up to date?
Asking
April 1st, 2023, 8:57 AM Eastern Time
Like, shots? Feels like I get them every time I’m at the doctor’s. Mom says they’re for school, but I don’t like them.
Your mom’s right, vaccinations help protect against diseases.
Educating
April 1st, 2023, 8:59 AM Eastern Time
Gotcha.
Do you have allergies during certain seasons?
Asking
April 1st, 2023, 8:59 AM Eastern Time
I don’t think so.
Any food allergies?
Asking
April 1st, 2023, 8:59 AM Eastern Time
I don’t think I’m allergic to anything.
Any medication allergies?
Asking
April 1st, 2023, 9:00 AM Eastern Time
Don’t think so.
Family history of asthma?
Asking
April 1st, 2023, 9:00 AM Eastern Time
Only my dad had it, I think.
Family history of allergies?
Asking
April 1st, 2023, 9:00 AM Eastern Time
I’m not sure.
Do you experience chills?
Asking
April 1st, 2023, 9:01 AM Eastern Time
Not feeling any chills.
Do you have a fever?
Asking
April 1st, 2023, 9:01 AM Eastern Time
Mom said I didn’t have one this morning.
Are you feeling tired?
Asking
April 1st, 2023, 9:01 AM Eastern Time
Yeah, kinda tired. Think it’s from not sleeping well with all the coughing.
Sorry about that.
Expressing Sympathy
April 1st, 2023, 9:01 AM Eastern Time
Thanks.
Do you experience night sweats?
Asking
April 1st, 2023, 9:02 AM Eastern Time
Only if it gets really hot.
Do you get frequent colds?
Asking
April 1st, 2023, 9:02 AM Eastern Time
Yeah, seems like I catch colds often. Nose is always runny.
Do you get headaches?
Asking
April 1st, 2023, 9:02 AM Eastern Time
Not really.
Alcohol Use Disorder Rachel Adler shadow health Documentation
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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Question |
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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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Question |
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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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Question |
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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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Question |
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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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Educate |
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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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Educate |
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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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Question |
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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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Question |
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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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Educate |
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Oh, OK.
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Are you usually active?
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Question |
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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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Question |
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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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Question |
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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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Question |
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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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Question |
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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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Question |
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It’s kind of clear and, like, watery.
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Any ear pain?
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Question |
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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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Question |
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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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Question |
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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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Question |
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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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Question |
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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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Question |
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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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Question |
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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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Educate |
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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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Question |
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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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Question |
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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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Question |
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Only Papi had asthma, I think.
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Any family history of allergies?
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Question |
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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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Question |
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No, I haven’t felt that.
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Do you have fever?
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Question |
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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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Question |
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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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Question |
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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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Question |
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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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Question |
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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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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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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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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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