Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

Danny Rivera Pediatric Cough Shadow Health Assessment Transcript
Transcript

Started: Apr 08, 2020 | Total Time: 74 min

All Lines (176)Interview Questions (58)Statements (19)Exam Actions (99)

Hello. My name is Pam and I will be interviewing today and later do a physical examination.

Greet
04/08/20 9:01 PM PDT

Hi.

What is your name?

Question
04/08/20 9:01 PM PDT

My name is Daniel Rivera, but I just go by Danny.

What brings you to the clinic today?

SCORE 100% ON YOUR SHADOW HEALTH ASSESSMENT

Question
04/08/20 9:01 PM PDT

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
04/08/20 9:02 PM PDT

Thank you.

Do you have a cough?

Question
04/08/20 9:03 PM PDT

I guess I’m kind of sick. . . I’ve been coughing a lot.

How long have you had a cough?

Question
04/08/20 9:03 PM PDT

I think the cough started four. . . No, it started five days ago. Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

Is your cough a wet or a dry one?

Question
04/08/20 9:03 PM PDT

My cough seems kind of gurgly and watery.

That sounds like a wet cough

Educate
04/08/20 9:04 PM PDT

Oh, OK.

Do yxxx

Question
04/08/20 9:05 PM PDT

Isxxx

Am sorry to hear this.

Empathize
04/08/20 9:05 PM PDT

Thank you.

Howxxx

Question
04/08/20 9:06 PM PDT

I jxx

Do thexxx

Question
04/08/20 9:07 PM PDT

Most timesxxx

Am sorry to hear this.

Empathize
04/08/20 9:08 PM PDT

Thank you.

Do youxxx

Question
04/08/20 9:08 PM PDT

No way! I knowxxx

True, xxx

Educate
04/08/20 9:09 PM PDT

Oh, OK.

Are you ever aroundxxxx

Question
04/08/20 9:13 PM PDT

Well . . . sometimes xxx

Am sorry about that, i xxx

Question
04/08/20 9:14 PM PDT

Am sorry about that, i understand your concerns.

Empathize
04/08/20 9:14 PM PDT

Thank you.

What makes your coughs worse?

Question
04/08/20 9:15 PM PDT

My cough mostly stays the same no matter what I do. It seems to get worse at night though.

Have you triedxxx

Question
04/08/20 9:15 PM PDT

I had somexxx. [AUDIO COMING SOON]

What is the xxx

Question
04/08/20 9:16 PM PDT

I don’t know whatxxx

Who xxx

Question
04/08/20 9:17 PM PDT

My xxx

how muchxxx

Question
04/08/20 9:17 PM PDT

I just hadxxx

How xxx

Question
04/08/20 9:18 PM PDT

I only xxx. [AUDIO COMING SOON]

Apart from thexxx

Question
04/08/20 9:18 PM PDT

Do youxxx

Question
04/08/20 9:20 PM PDT

Oh yeah, I xxx

I understand, its xxx

Educate
04/08/20 9:21 PM PDT

Oh, OK.

Are you usually active?

Question
04/08/20 9:22 PM PDT

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, its healthy.

Educate
04/08/20 9:23 PM PDT

Oh, OK.

Does the cough make you less active?

Question
04/08/20 9:24 PM PDT

No, that doesn’t help my cough.

Are you able to focus in class?

Question
04/08/20 9:24 PM PDT

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 the cough is disturbing you sometimes. (No matching questions found.)

Question
04/08/20 9:24 PM PDT

Am sorry to hear that the cough is disturbing you sometimes.

Empathize
04/08/20 9:25 PM PDT

Thank you.

Do you xxx

Question
04/08/20 9:28 PM PDT

My xx

Am sorry about this

Empathize
04/08/20 9:28 PM PDT

Thank you.

Have you xxx

Question
04/08/20 9:28 PM PDT

I don’t xxx

what xxx

Question
04/08/20 9:29 PM PDT

You mean likexxxx

Yes, that one. Ok, thanks.

Educate
04/08/20 9:30 PM PDT

Oh, OK.

How consistent is xxx

Question
04/08/20 9:38 PM PDT

It’s kind of xxx

xx

Question
04/08/20 9:41 PM PDT

My xxx . . . my left one is OK though.

Am sorry to hear this Danny

Empathize
04/08/20 9:42 PM PDT

Thank you.

Do you havexxx

Question
04/08/20 9:42 PM PDT

No, xxxkind of hurts.

Do you have xxx problems?

Question
04/08/20 9:42 PM PDT

A lady came to my school to xx . . . Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

Great, its good to have a test done whenever there is a chance.

Educate
04/08/20 9:43 PM PDT

Oh, OK.

Do you have soar throat?

Question
04/08/20 9:44 PM PDT

It feels a little bit sore, yeah.

Does it xxx

Question
04/08/20 9:45 PM PDT

No, I can xxxx

Sorry about that Danny

Empathize
04/08/20 9:45 PM PDT

Thank you.

Have you xxx

Question
04/08/20 9:46 PM PDT

Do you have difficulty breathing?

Question
04/08/20 9:58 PM PDT

I can breathe OK, yeah . . . my nose is a little bit runny though.

Thank you for answering the questions Danny. I will now do the physical examination.

Question
04/08/20 9:59 PM PDT

I don’t have any questions really.

Thank you for answering the questions, i will now do the physical examination on you.

Educate
04/08/20 10:00 PM PDT

Oh, OK.

Checked vitals

Exam Action
04/09/20 11:08 AM PDT

Tested lung capacity with spirometer: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%) Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

Exam Action
04/09/20 11:12 AM PDT

Inspected upper conjunctiva

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04/09/20 11:14 AM PDT

Inspected upper conjunctiva

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Inspected upper conjunctiva

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Inspected lower conjunctiva

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Inspected right orbital area and sclera

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Inspected left orbital area and sclera

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04/09/20 11:15 AM PDT

Performed otoscopic examination of right naris

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Performed otoscopic examination of left naris

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Performed otoscopic examination of right ear

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Performed otoscopic examination of left ear

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Inspected mouth

Exam Action
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Inspected front of neck

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Inspected right side of neck

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Inspected front of neck

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Inspected left side of neck

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Inspected back of neck

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Inspected anterior chest wall

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Inspected posterior chest wall

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Inspected anterior chest wall

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Palpated frontal sinuses: No tenderness reported

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04/09/20 11:19 AM PDT

Palpated maxillary sinuses: No tenderness reported

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Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side

Exam Action
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Palpated supraclavicular lymph nodes: Not palpable

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Palpated axillary lymph nodes: Not palpable

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Palpated axillary lymph nodes: Not palpable

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04/09/20 11:23 AM PDT

Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally

Exam Action
04/09/20 11:24 AM PDT

Ninety-nine.

Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally

Exam Action
04/09/20 11:24 AM PDT

Ninety-nine.

Palpated fremitus in posterior upper chest wall: Expected fremitus, equal bilaterally

Exam Action
04/09/20 11:24 AM PDT

Ninety-nine.

SCORE 100% ON YOUR SHADOW HEALTH ASSESSMENT

Palpated fremitus in posterior middle chest wall: Expected fremitus, equal bilaterally

Exam Action
04/09/20 11:24 AM PDT

Ninety-nine.

Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally

Exam Action
04/09/20 11:24 AM PDT

Ninety-nine.

Auscultated breath sounds in anterior left upper lobe

Exam Action
04/09/20 11:25 AM PDT

Auscultated breath sounds in anterior right upper lobe

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Auscultated breath sounds in anterior right middle lobe

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04/09/20 11:26 AM PDT

Auscultated breath sounds in anterior left mid-chest (upper lobe)

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Auscultated breath sounds in anterior left mid-chest (upper lobe)

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Auscultated breath sounds in anterior right middle lobe

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Auscultated breath sounds in anterior right lower lobe

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Auscultated breath sounds in anterior left lower lobe

Exam Action
04/09/20 11:27 AM PDT

Auscultated breath sounds in posterior left upper lobe

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Auscultated breath sounds in posterior right upper lobe

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Auscultated breath sounds in posterior right mid-back (lower lobe)

Exam Action
04/09/20 11:27 AM PDT

Auscultated breath sounds in posterior left mid-back (lower lobe)

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04/09/20 11:27 AM PDT

Auscultated breath sounds in posterior right lower lobe near spine

Exam Action
04/09/20 11:28 AM PDT

Auscultated breath sounds in posterior left lower lobe near spine

Exam Action
04/09/20 11:28 AM PDT

Auscultated breath sounds in posterior left lower lobe on side

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04/09/20 11:28 AM PDT

Auscultated breath sounds in posterior left lower lobe

Exam Action
04/09/20 11:28 AM PDT

Auscultated breath sounds in posterior right lower lobe

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04/09/20 11:28 AM PDT

Auscultated breath sounds in posterior right lower lobe on side

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04/09/20 11:28 AM PDT

Auscultated voice sounds in anterior right upper lobe

Exam Action
04/09/20 11:29 AM PDT

Ninety-nine.

Auscultated voice sounds in anterior left upper lobe
Danny Rivera Pediatric Cough Shadow Health Assessment Transcript

Exam Action
04/09/20 11:29 AM PDT

Ninety-nine.

Auscultated voice sounds in anterior left mid-chest (upper lobe)

Exam Action
04/09/20 11:29 AM PDT

Ninety-nine.

Auscultated voice sounds in anterior right middle lobe

Exam Action
04/09/20 11:29 AM PDT

Ninety-nine.

Auscultated voice sounds in anterior right middle lobe

Exam Action
04/09/20 11:30 AM PDT

Ninety-nine.

Auscultated voice sounds in anterior left mid-chest (upper lobe)

Exam Action
04/09/20 11:30 AM PDT

Ninety-nine.

Auscultated voice sounds in anterior left lower lobe

Exam Action
04/09/20 11:30 AM PDT

Ninety-nine.

Auscultated voice sounds in anterior right lower lobe

Exam Action
04/09/20 11:30 AM PDT

Ninety-nine.

Auscultated voice sounds in posterior left upper lobe

Exam Action
04/09/20 11:30 AM PDT

Ninety-nine.

Auscultated voice sounds in posterior right upper lobe

Exam Action
04/09/20 11:30 AM PDT

Ninety-nine.

Auscultated voice sounds in posterior right mid-back (lower lobe)

Exam Action
04/09/20 11:30 AM PDT

Auscultated voice sounds in posterior left mid-back (lower lobe)

Exam Action
04/09/20 11:30 AM PDT

Ninety-nine.

Auscultated voice sounds in posterior left lower lobe near spine

Exam Action
04/09/20 11:30 AM PDT

Ninety-nine.

Auscultated voice sounds in posterior right lower lobe near spine

Exam Action
04/09/20 11:30 AM PDT

Ninety-nine.

Auscultated voice sounds in posterior right lower lobe on side

Exam Action
04/09/20 11:30 AM PDT

Ninety-nine.

Auscultated voice sounds in posterior right lower lobe