Watch the following videos, then complete the required assignment.Fill in the guide for each lab——————————————-Lab 1 coughHTTPS://www.dailymotion.com/video/x6iwx1m————————————————https://www.dailymotion.com/video/x6iwyqgLab 2OSCE Clinical SkillsSore throat 15:08Upon completion of watching the video write up the scenario into a SOAP format. Is there anything you would do differently on your plan?Lab 2OSCE Clinical SkillsCough 16:29Upon completion of watching the video write up the scenario into a SOAP format. Is there anything you would do differently on your plan?——————————————History and InterviewThe following guide will assist you in gathering subjective data in an organized, systematic manner to prevent omission of important components of the health history.Date of History/Interview:Source of history and Reliability:Biographical Dataa. Name (use initials only)b. Primary languagec. Age and Date of Birthd. Place of Birthe. Genderf. Raceg. Marital Statush. Ethnic/Cultural Origini. Education ( highest level completed)j. Occupation/Professionalk. Health insurance (ie commercial, state, federal)2. Chief Complaint (reason for seeking health care):a. Brief spontaneous statement in client’s own wordsb. Includes when the problem started ( “chest pain for 2 hours”)3. History of Present Illness: A well organized, chronological record of client’s reason for seeking care, from time of onset to present. Please include the 8 critical characteristics using the OLD CARTS pneumonic.P – Provocative or palliative (What brings it on? What makes it better or worse?)Q – Quality or quantity (Describe the character and location of the symptoms; How does it look, feel, sound?)R – Region or radiation (Where is it? Does the symptom radiate to other areas of the body?).S – Severity (Ask the patient to quantify the symptom(s) on a scale of 0-10).T – Timing (Inquire about time of onset, duration, frequency, etc.)U – Understand Patient’s Perception of the problem (What do you think it means?)** Put all of that information into the heading HPI in a story format.4. Past Medical History (list down not across)a. Medical Hx: major illnesses during life span, injuries, hospitalizations, transfusions, and disabilitiesb. Childhood Illnesses: Measles, mumps, rubella, chickenpox, pertussis, strep throatc. Surgical Hx; procedures, dates, inpatient or outpatientd. Obstetric HX: Number of pregnancies, term deliveries, preterm births, abortions(spontaneous or induced), number of children livinge. Immunizationsf. Psychiatric Hx: childhood and adult (treated or hx of)g. Allergies: Medications, food, inhalants or other (what occurs with reaction)h. Current Medications: Include all prescription, herbal/supplements and OTC, dosage, frequencyi. Last Examination Date: Physical, eye exam, foot exam, dental exam, hearing screen, EKG, chest X-Ray, Pap test, mammogram, serum cholesterol, stool occult blood, prostate, PSA, UA, TB skin test; other health maintenance tests for infants/children may include sickle-cell, PKU, lead level, and hematocrit5. Family History list FHxa. Include parents, grandparents, spouse, and children.b. Health conditions, familial and communicable diseases/illnessesc. Note whether family member deceased or livingII. Life style patternsa. Immigrant statusb. Spiritual resources/religionc. Health perceptiond. Nutritional patterns: Appetite (any changes); satisfaction with current weight; gains or losses; recall of usual intake; any cultural restrictions/intolerances; amount of fluid per day and typee. Elimination patterns: Bowel (usual pattern and characteristics); bladder (usual pattern and characteristics); any incontinencef. Living environment: City, state; urban, rural, community; type of dwelling, facilities; known exposures to environmental toxinsg. Occupational health: Known exposure to environmental toxins at workh. Functional assessment: ADLs, IADLs, interpersonal relationships/resources (see page 57 in Jarvis textbook)i. Role and family relationships: Immediate family composition; how are family decisions made; impact of family member’s health on familyj. Cognitive function: Memory; speech; judgment; sensesk. Rest/sleep patterns: Number of hours; naps; number of pillows; any aids for sleepl. Exercise patterns: Type and frequencym. Hobbies/recreation: Leisure activities; any travel outside of the USn. Social habits: Tobacco; alcohol; street drug useo. Intimate partner violence (review screening questions on page 58 in the Jarvis textbook)p. Coping/stress management: Any major life change in past 2 years; do you feel tense; source; what helpsq. Sexual patterns: Are you sexually active; gender preference; has anything changed about your sexual health/functionIII. Review of SymptomsSymptoms to Inquire About(please see page 54–56 in Jarvis textbook)Document pertinent negatives and/or positivesThe first system is addressed to provide a guideGeneralWgt Δ; weakness; fatigue; feversPertinent negatives: No weight gain or losses; no weaknesses, fatigue, or feversPertinent positives: Positive weight gain over past 2 months with fatigue and weakness; no feversSkinRash; lumps; sores; itching; dryness; color change; Δ in hair/nailsHeadHeadache; head injury; dizziness or vertigoEyesVision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotomaEarsHearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid useNose/SinusesColds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus painThroat/MouthBleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered tasteNeckLumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motionBreastsLumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla areaPulmonaryCough — productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest x-ray, TB skin testCardiacChest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CADG/IAppetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intoleranceGUFrequency; nocturia; urgency; dysuria; hematuria; incontinenceFemales: Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps; menopause; hot flashes; post-menopausal bleeding;Males: Caliber of urinary stream; hesitancy; dribbling; hernia, sexual habits, interest, function, satisfaction; discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how oftenPeripheral VascularClaudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcersMusculo-skeletalMuscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk diseaseNeuroSyncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations HemeHx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiationEndoHeat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid disease; hormone replacement; abnormal hair distributionPsychNervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses
