Education and Empathy

Your Results Subjective Data Collection: 22 of 22 (100.0%) Category 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. 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 yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports cough History of Presenting Illness Asked about onset of cough Asked about characteristics of cough Reports cough started 3 days ago Reports cough is wet Reports clear sputum with cough Asked about frequency and duration of Reports coughing every few minutes cough Reports coughs last a few seconds Asked about aggravating factors for cough Reports cough is worse at night Denies smoking Reports being exposed to secondhand smoke through father Reports he doesn't know what triggers the cough Asked about exposure to germs Asked about hand hygiene Reports playing with an ill classmate Reports infrequent hand washing Reports occasionally putting fingers in eyes, nose, or mouth Asked about cough etiquette Asked about relieving factors for cough Followed up on cough medicine Denies covering mouth when coughing Reports cough is temporarily relieved by cough medicine Reports cough medicine was purple Reports taking one spoonful of cough medicine Reports mother gave him the medicine Reports only took the medicine this morning Denies home remedies Asked about typical medication use Denies taking medication Reports taking daily vitamin Asked about activity level Reports typical high activity level Reports activity level low since getting sick Reports still able to run or play Reports focusing in class is difficult Asked about nasal symptoms Reports current runny nose Denies sneezing Followed up on nasal discharge Reports nasal discharge is clear Reports nasal discharge is thin Asked about ear symptoms Denies ear pain Reports history of frequent ear infections Denies ear discharge Denies hearing problems Asked about throat symptoms Reports sore throat Reports a little pain with swallowing Past Medical History Asked about relevant medical history Reports frequent runny noses Reports past frequent coughs Reports past pneumonia Denies asthma diagnosis Reports immunizations as current Asked about allergies Denies seasonal allergies Denies food allergies Denies medication allergies Asked relevant family history Reports father has history of asthma Denies family history of allergies Review of Systems Asked about constitutional health Denies chills Denies fever Reports feeling somewhat fatigued Denies night sweats Reports cough makes it difficult to sleep Denies swelling Asked about additional review of systems for HEENT Reports frequent colds Denies headaches Denies nosebleeds Denies vision difficulty Denies dizziness Denies watery eyes Denies eye redness Denies eye pain Denies sinus pain Asked about review of systems for respiratory Denies chest tightness Denies chest pain Your Results Objective Data Collection: 14.6 of 15 (97.33%) Correct Incorrect Partially correct Missed Inspected eyes and orbital area Orbital Area (1/4 point) 1 of 1 point Sclera (1/4 point) No visible abnormal findings White Ptosis Yellow tint Eyelid Redness Lesion Conjunctiva (1/4 point) Conjunctival Discharge (1/4 point) Moist and pink No discharge Dry appearance Clear, watery discharge Redness Purulent discharge Swelling Inspected nasal cavities 1 of 1 point Color (1/4 point) Discharge (1/4 point) Pink No discharge Red 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 (1/10 point) 1 of 1 point Right: Tympanic Membrane Color (1/10 point) Pink Pearly gray Red Red 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 Red 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 Red 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 0.6 of 1 point Oral Mucosa (1/5 point) Tonsils (1/5 point) Moist and pink No visible abnormal findings Dry appearance Swelling Redness Throat Color (1/5 point) Redness Throat Texture (1/5 point) Pink No abnormal findings Red 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) 1 of 1 point Appearance (1/2 point) Symmetric No visible abnormal findings Asymmetric Rash Barrel chest Intercostal retraction while breathing Excessive use of accessory muscles while breathing Skin growths (freckles or moles) Auscultated breath sounds Breath Sounds (1/3 point) 1 of 1 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 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 Observations (1/2 point) 1 of 1 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 Measured diaphragmatic excursion 1 of 1 point Range (1/1 point) 3-5 cm Greater than 3-5 cm Less than 3-5 cm 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 1 of 1 point Head And Neck (1/3 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 Palpated chest expansion Symmetry (1/1 point) Equal bilaterally Unequal bilaterally 1 of 1 point