Pediatric Cough Shadow Health Assessment Transcript: Danny Rivera
|
Hello. My name is Pam and I will be interviewing today and later doing 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?
|
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, it’s 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, it’s 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, xxx kind 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, it’s good to have a test done whenever there is a chance. |
Educate 04/08/20 9:43 PM PDT |
|
Oh, OK. |
|
|
Do you have a 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 |
Exam Action 04/09/20 11:14 AM PDT |
|
Inspected upper conjunctiva |
Exam Action 04/09/20 11:14 AM PDT |
|
Inspected upper conjunctiva |
Exam Action 04/09/20 11:14 AM PDT |
|
Inspected lower conjunctiva |
Exam Action 04/09/20 11:14 AM PDT |
|
Inspected right orbital area and sclera |
Exam Action 04/09/20 11:14 AM PDT |
|
Inspected left orbital area and sclera |
Exam Action 04/09/20 11:15 AM PDT |
|
Performed otoscopic examination of right naris |
Exam Action 04/09/20 11:15 AM PDT |
|
Performed otoscopic examination of left naris |
Exam Action 04/09/20 11:15 AM PDT |
|
Performed otoscopic examination of the right ear |
Exam Action 04/09/20 11:16 AM PDT |
|
Performed otoscopic examination of left ear |
Exam Action 04/09/20 11:16 AM PDT |
|
Inspected mouth |
Exam Action 04/09/20 11:16 AM PDT |
|
Inspected the front of the neck |
Exam Action 04/09/20 11:16 AM PDT |
|
Inspected the right side of the neck |
Exam Action 04/09/20 11:17 AM PDT |
|
Inspected the front of the neck |
Exam Action 04/09/20 11:17 AM PDT |
|
Inspected the left side of the neck |
Exam Action 04/09/20 11:17 AM PDT |
|
Inspected the back of the neck |
Exam Action 04/09/20 11:17 AM PDT |
|
Inspected anterior chest wall |
Exam Action 04/09/20 11:17 AM PDT |
|
Inspected posterior chest wall |
Exam Action 04/09/20 11:17 AM PDT |
|
Inspected anterior chest wall |
Exam Action 04/09/20 11:17 AM PDT |
|
Palpated frontal sinuses: No tenderness was reported |
Exam Action 04/09/20 11:19 AM PDT |
|
Palpated maxillary sinuses: No tenderness reported |
Exam Action 04/09/20 11:20 AM PDT |
|
Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side |
Exam Action 04/09/20 11:23 AM PDT |
|
Palpated supraclavicular lymph nodes: Not palpable |
Exam Action 04/09/20 11:23 AM PDT |
|
Palpated axillary lymph nodes: Not palpable |
Exam Action 04/09/20 11:23 AM PDT |
|
Palpated axillary lymph nodes: Not palpable |
Exam Action 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.
|
|
|
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 the anterior left upper lobe |
Exam Action 04/09/20 11:25 AM PDT |
|
Auscultated breath sounds in the anterior right upper lobe |
Exam Action 04/09/20 11:25 AM PDT |
|
Auscultated breath sounds in the anterior right middle lobe |
Exam Action 04/09/20 11:26 AM PDT |
|
Auscultated breath sounds in the anterior left mid-chest (upper lobe) |
Exam Action 04/09/20 11:26 AM PDT |
|
Auscultated breath sounds in the anterior left mid-chest (upper lobe) |
Exam Action 04/09/20 11:26 AM PDT |
|
Auscultated breath sounds in the anterior right middle lobe |
Exam Action 04/09/20 11:26 AM PDT |
|
Auscultated breath sounds in the anterior right lower lobe |
Exam Action 04/09/20 11:26 AM PDT |
|
Auscultated breath sounds in the anterior left lower lobe |
Exam Action 04/09/20 11:27 AM PDT |
|
Auscultated breath sounds in the posterior left upper lobe |
Exam Action 04/09/20 11:27 AM PDT |
|
Auscultated breath sounds in the posterior right upper lobe |
Exam Action 04/09/20 11:27 AM PDT |
|
Auscultated breath sounds in the posterior right mid-back (lower lobe) |
Exam Action 04/09/20 11:27 AM PDT |
|
Auscultated breath sounds in the posterior left mid-back (lower lobe) |
Exam Action 04/09/20 11:27 AM PDT |
|
Auscultated breath sounds in the posterior right lower lobe near the spine |
Exam Action 04/09/20 11:28 AM PDT |
|
Auscultated breath sounds in the posterior left lower lobe near the spine |
Exam Action 04/09/20 11:28 AM PDT |
|
Auscultated breath sounds in the posterior left lower lobe on the side |
Exam Action 04/09/20 11:28 AM PDT |
|
Auscultated breath sounds in the posterior left lower lobe |
Exam Action 04/09/20 11:28 AM PDT |
|
Auscultated breath sounds in the posterior right lower lobe |
Exam Action 04/09/20 11:28 AM PDT |
|
Auscultated breath sounds in the posterior right lower lobe on the side |
Exam Action 04/09/20 11:28 AM PDT |
|
Auscultated voice sounds in the anterior right upper lobe |
Exam Action 04/09/20 11:29 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated voice sounds in the anterior left upper lobe
Danny Rivera Pediatric Cough Shadow Health Assessment Transcript |
Exam Action 04/09/20 11:29 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated voice sounds in the anterior left mid-chest (upper lobe) |
Exam Action 04/09/20 11:29 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated voice sounds in the anterior right middle lobe |
Exam Action 04/09/20 11:29 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated voice sounds in the anterior right middle lobe |
Exam Action 04/09/20 11:30 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated voice sounds in the anterior left mid-chest (upper lobe) |
Exam Action 04/09/20 11:30 AM PDT |
|
Ninety-nine. |
|
|
Auscultated voice sounds in the anterior left lower lobe |
Exam Action 04/09/20 11:30 AM PDT |
|
Ninety-nine. |
|
|
Auscultated voice sounds in the anterior right lower lobe |
Exam Action 04/09/20 11:30 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated voice sounds in the posterior left upper lobe |
Exam Action 04/09/20 11:30 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated voice sounds in the posterior right upper lobe |
Exam Action 04/09/20 11:30 AM PDT |
|
Ninety-nine. |
|
|
Auscultated voice sounds in the posterior right mid-back (lower lobe) |
Exam Action 04/09/20 11:30 AM PDT |
|
Auscultated voice sounds in the posterior left mid-back (lower lobe) |
Exam Action 04/09/20 11:30 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated voice sounds in the posterior left lower lobe near the spine |
Exam Action 04/09/20 11:30 AM PDT |
|
Ninety-nine. |
|
|
Auscultated voice sounds in the posterior right lower lobe near the spine |
Exam Action 04/09/20 11:30 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated voice sounds in the posterior right lower lobe on the side |
Exam Action 04/09/20 11:30 AM PDT |
|
Ninety-nine. |
|
|
Auscultated voice sounds in the posterior right lower lobe |
Exam Action 04/09/20 11:31 AM PDT |
|
Ninety-nine. |
|
|
Auscultated voice sounds in the posterior left lower lobe |
Exam Action 04/09/20 11:31 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated voice sounds in the posterior left lower lobe on the side |
Exam Action 04/09/20 11:31 AM PDT |
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Ninety-nine. |
|
|
Auscultated aortic area with the bell |
Exam Action 04/09/20 11:31 AM PDT |
|
Auscultated aortic area with the diaphragm |
Exam Action 04/09/20 11:31 AM PDT |
|
Auscultated aortic area with the bell |
Exam Action 04/09/20 11:31 AM PDT |
|
Auscultated aortic area with the diaphragm |
Exam Action 04/09/20 11:31 AM PDT |
|
Auscultated aortic area with the bell |
Exam Action 04/09/20 11:31 AM PDT |
|
Auscultated aortic area with the diaphragm |
Exam Action 04/09/20 11:31 AM PDT |
|
Auscultated pulmonic area with the diaphragm |
Exam Action 04/09/20 11:31 AM PDT |
|
Auscultated pulmonic area with the bell |
Exam Action 04/09/20 11:31 AM PDT |
|
Auscultated Erb’s point with the bell |
Exam Action 04/09/20 11:31 AM PDT |
|
Auscultated Erb’s point with the diaphragm |
Exam Action 04/09/20 11:32 AM PDT |
|
Auscultated tricuspid area with the diaphragm |
Exam Action 04/09/20 11:32 AM PDT |
|
Auscultated tricuspid area with the bell |
Exam Action 04/09/20 11:32 AM PDT |
|
Auscultated mitral area with the bell |
Exam Action 04/09/20 11:32 AM PDT |
|
Auscultated mitral area with the diaphragm |
Exam Action 04/09/20 11:32 AM PDT |
|
Percussed anterior right upper lobe |
Exam Action 04/09/20 11:32 AM PDT |
|
Percussed anterior right middle lobe |
Exam Action 04/09/20 11:32 AM PDT |
|
Percussed anterior left upper lobe |
Exam Action 04/09/20 11:32 AM PDT |
|
Percussed anterior left mid-chest (upper lobe) |
Exam Action 04/09/20 11:32 AM PDT |
|
Percussed anterior left lower lobe |
Exam Action 04/09/20 11:32 AM PDT |
|
Percussed anterior right lower lobe |
Exam Action 04/09/20 11:32 AM PDT |
|
Percussed posterior left upper lobe |
Exam Action 04/09/20 11:33 AM PDT |
|
Percussed posterior left mid-back (lower lobe) |
Exam Action 04/09/20 11:33 AM PDT |
|
Percussed posterior right mid-back (lower lobe) |
Exam Action 04/09/20 11:33 AM PDT |
|
Percussed posterior right upper lobe |
Exam Action 04/09/20 11:33 AM PDT |
|
Percussed posterior left lower lobe |
Exam Action 04/09/20 11:33 AM PDT |
|
Percussed posterior left lower lobe on the side |
Exam Action 04/09/20 11:33 AM PDT |
|
Percussed posterior left lower lobe near the spine |
Exam Action 04/09/20 11:33 AM PDT |
|
Percussed posterior right lower lobe near the spine |
Exam Action 04/09/20 11:33 AM PDT |
|
Percussed posterior right lower lobe |
Exam Action 04/09/20 11:33 AM PDT |
|
Percussed posterior left right lobe on the side |
Exam Action 04/09/20 11:33 AM PDT |
|
Inspected mouth
Danny Rivera Pediatric Cough Shadow Health Assessment Transcript |
Exam Action 04/09/20 11:58 AM PDT |