Transcript
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Hello. My name is Pam and I will be interviewing today and later do a physical examination.
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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. Danny Rivera Pediatric Cough Shadow Health Assessment Transcript
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Is your cough a wet or a dry one?
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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 yxxx
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Isxxx
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Am sorry to hear this.
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Empathize |
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Thank you.
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Howxxx
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I jxx
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Do thexxx
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Most timesxxx
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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 youxxx
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No way! I knowxxx
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True, xxx
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Educate |
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Oh, OK.
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Are you ever aroundxxxx
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Question |
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Well . . . sometimes xxx
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Am sorry about that, i xxx
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Question |
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Am sorry about that, i understand your concerns.
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Empathize |
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Thank you.
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What makes your coughs 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 triedxxx
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I had somexxx. [AUDIO COMING SOON]
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What is the xxx
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I don’t know whatxxx
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Who xxx
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My xxx
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how muchxxx
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I just hadxxx
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How xxx
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I only xxx. [AUDIO COMING SOON]
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Apart from thexxx
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Do youxxx
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Oh yeah, I xxx
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I understand, its xxx
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Educate |
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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, its healthy.
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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 the cough is disturbing you sometimes. (No matching questions found.)
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Question |
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Am sorry to hear that the cough is disturbing you sometimes.
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Empathize |
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Thank you.
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Do you xxx
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My xx
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Am sorry about this
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Empathize |
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Thank you.
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Have you xxx
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I don’t xxx
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what xxx
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You mean likexxxx
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Yes, that one. Ok, thanks.
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Educate |
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Oh, OK.
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How consistent is xxx
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It’s kind of xxx
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My xxx . . . my left one is OK though.
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Am sorry to hear this Danny
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Empathize |
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Thank you.
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Do you havexxx
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No, xxxkind of hurts.
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Do you have xxx problems?
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A lady came to my school to xx . . . Danny Rivera Pediatric Cough Shadow Health Assessment Transcript
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Great, 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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Do you have soar throat?
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It feels a little bit sore, yeah.
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Does it xxx
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No, I can xxxx
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Sorry about that Danny
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Empathize |
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Thank you.
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Have you xxx
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Do you have difficulty breathing?
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I can breathe OK, yeah . . . my nose is a little bit runny though.
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Thank you for answering the questions Danny. I will now do the physical examination.
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I don’t have any questions really.
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Thank you for answering the questions, i will now do the physical examination on you.
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Educate |
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Oh, OK.
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Checked vitals
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Exam Action |
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Tested lung capacity with spirometer: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%) Danny Rivera Pediatric Cough Shadow Health Assessment Transcript
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Inspected upper conjunctiva
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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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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
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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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Palpated maxillary sinuses: No tenderness reported
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Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side
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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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Palpated fremitus in anterior upper chest wall: Expected fremitus, equal bilaterally
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Ninety-nine.
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Palpated fremitus in anterior lower chest wall: Expected fremitus, equal bilaterally
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Ninety-nine.
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Palpated fremitus in posterior upper chest wall: Expected fremitus, equal bilaterally
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Ninety-nine.
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Palpated fremitus in posterior middle chest wall: Expected fremitus, equal bilaterally
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Ninety-nine.
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Palpated fremitus in posterior lower chest wall: Expected fremitus, equal bilaterally
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Ninety-nine.
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Auscultated breath sounds in anterior left upper lobe
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Auscultated breath sounds in anterior right upper lobe
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Auscultated breath sounds in anterior right middle lobe
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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
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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)
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Auscultated breath sounds in posterior left mid-back (lower lobe)
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Auscultated breath sounds in posterior right lower lobe near spine
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Auscultated breath sounds in posterior left lower lobe near spine
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Auscultated breath sounds in posterior left lower lobe on side
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Auscultated breath sounds in posterior left lower lobe
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Auscultated breath sounds in posterior right lower lobe
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Auscultated breath sounds in posterior right lower lobe on side
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Auscultated voice sounds in anterior right upper lobe
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in anterior left upper lobe
Danny Rivera Pediatric Cough Shadow Health Assessment Transcript
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Exam Action |
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Ninety-nine.
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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 mid-chest (upper 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 anterior right middle lobe
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Exam Action |
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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 right middle 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 anterior left mid-chest (upper lobe)
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Exam Action |
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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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Auscultated voice sounds in anterior right lower lobe
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Exam Action |
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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 posterior left upper 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 upper lobe
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Exam Action |
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Ninety-nine.
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Auscultated voice sounds in posterior right mid-back (lower lobe)
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Exam Action |
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Auscultated voice sounds in posterior left mid-back (lower lobe)
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Exam Action |
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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 posterior left lower lobe near spine
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Exam Action |
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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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Ninety-nine.
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Auscultated voice sounds in posterior right 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 right lower lobe
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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 left lower lobe on side
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Exam Action |
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Ninety-nine.
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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 aortic area with the diaphragm
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Auscultated aortic area with the bell
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Auscultated aortic area with the diaphragm
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Auscultated aortic area with the bell
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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 pulmonic area with the bell
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Auscultated Erb’s point with the bell
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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 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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Percussed anterior right upper lobe
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Percussed anterior right middle lobe
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Percussed anterior left upper lobe
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Percussed anterior left mid-chest (upper lobe)
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Percussed anterior left lower lobe
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Percussed anterior right lower lobe
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Percussed posterior left 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 right upper lobe
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Percussed posterior left 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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Percussed posterior right lower lobe
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Percussed posterior left right lobe on side
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Inspected mouth
Danny Rivera Pediatric Cough Shadow Health Assessment Transcript
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