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Focused Exam: Cough, Danny Rivera Shadow health

Focused Exam: Cough, Danny Rivera Shadow health

Objective Data Collection: 13 of 13 (100%)

 Correct
 Partially correct

 Incorrect
 Missed

 Inspected eyes and orbital area
1 of 1 point
Orbital Area (1/4 point)

 No visible abnormal findings
 Ptosis
 Eyelid edema
 Lesion
 Allergic shiners
Focused Exam: Cough, Danny Rivera Shadow health

Sclera (1/4 point)

 White
 Jaundice
 Injection
 Icterus

Conjunctiva (1/4 point)

 Moist and pink
 Pale
 Dry appearance
 Erythema
 Edema

Conjunctival Discharge (1/4 point)

 No discharge
 Clear, watery discharge
 Purulent discharge
Focused Exam: Cough, Danny Rivera Shadow health

 Inspected nasal cavities
1 of 1 point
Color (1/4 point)

 Pink
 Erythemic
 Bluish

Discharge (1/4 point)

 No discharge
 Clear discharge
 Bloody discharge
 Purulent discharge

Turbinate Patency (1/4 point)

 Patent
 Decreased patency
 Not patent

Observations (1/4 point)

 No additional visible abnormal findings
 Foreign body present
 Polyp
 Septum perforated
 Septum deviated
 Lesion

 Inspected ears
1 of 1 point
Right: Auditory Canal Color (1/10 point)

 Pink
 Erythemic
 Pallor

Right: Tympanic Membrane Color (1/10 point)

 Pearly gray
 Erythemic
 Opaque
 Yellow
 Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 point)

 No visible abnormal findings
 Fluid observed
 Visible scars
 Bulging
 Perforation
 Retraction

Right: Cone Of Light (1/10 point)

 5:00
 Cone of light distorted

Right: Discharge (1/10 point)

 No discharge
 Cerumen
 Clear discharge
 Bloody discharge
 Purulent discharge

Left: Auditory Canal Color (1/10 point)

 Pink
 Erythemic
 Pallor

Left: Tympanic Membrane Color (1/10 point)

 Pearly gray
 Erythemic
 Opaque
 Yellow
 Not visible because of cerumen

Left: Tympanic Membrane Appearance (1/10 point)

 No visible abnormal findings
 Fluid observed
 Visible scars
 Bulging
 Perforation
 Retraction

Left: Cone Of Light (1/10 point)

 7:00
 Cone of light distorted

Left: Discharge (1/10 point)

 No discharge
 Cerumen
 Clear discharge
 Bloody discharge
 Purulent discharge

 Inspected mouth and throat
1 of 1 point
Oral Mucosa (1/5 point)

 Moist and pink
 Dry appearance
 Erythema

Tonsils (1/5 point)

 No visible abnormal findings
 Edema
 Erythema

Posterior Oropharynx Color (1/5 point)

 Pink
 Erythemic

Posterior Oropharynx Texture (1/5 point)

 No abnormal findings
 Cobblestoning
 Exudate

Post Nasal Drip (1/5 point)

 No discharge
 Clear discharge
 Purulent discharge

 Inspected neck
1 of 1 point
Symmetry (1/2 point)

 Symmetric
 Asymmetric

Appearance (1/2 point)

 No visible abnormal findings
 Swelling
 Visible pulsation
 Visible mass
 Discoloration

 Inspected chest
1 of 1 point
Symmetry (1/2 point)

 Symmetric
 Asymmetric

Appearance (1/2 point)

 No visible abnormal findings
 Rash or lesion
 AP diameter abnormal Intercostal retraction while breathing
 Excessive use of accessory muscles while breathing
 Pectus excavatum
 Skin growths (freckles or moles)
 Evidence of skin trauma (scar, laceration, or bruising)

 Palpated sinuses
1 of 1 point
Frontal (1/2 point)

 None reported
 Tenderness reported

Maxillary (1/2 point)

 None reported
 Tenderness reported

 Palpated lymph nodes
1 of 1 point
Cervical (1/3 point)

 No palpable nodes
 Palpable nodes on right side
 Palpable nodes on left side

Supraclavicular (1/3 point)

 No palpable nodes
 Palpable nodes on right side
 Palpable nodes on left side

Axillary (1/3 point)

 No palpable nodes
 Palpable nodes on right side
 Palpable nodes on left side
Focused Exam: Cough, Danny Rivera Shadow health

 Palpated fremitus
1 of 1 point
Symmetry (1/2 point)

 Equal bilaterally
 Unequal bilaterally

Vibration (1/2 point)

 Expected fremitus
 Decreased fremitus

 Auscultated breath sounds
1 of 1 point
Breath Sounds (1/3 point)

 Present in all areas
 Diminished in some areas
 Absent in some areas

Adventitious Sounds (1/3 point)

 No adventitious sounds
 Wheezing
 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
Focused Exam: Cough, Danny Rivera Shadow health

 Auscultated for bronchophony
1 of 1 point
Bronchophony (1/1 point)

 Positive
 Negative

 Auscultated heart sounds
1 of 1 point
Heart Sounds (1/2 point)

 S1 and S2 audible
 S1, S2, and S3 audible
 S1, S2, and S4 audible
 S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

 No extra sounds
 Gallops
 Murmur
 Friction rub
 Valve clicks

 Percussed chest wall
1 of 1 point
Observations (1/2 point)

 All areas resonant
 Some areas dull, some resonant
 Some areas hyperresonant, some resonant

Location (1/2 point)

 No areas of dullness
 Dullness, anterior right upper lobe
 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
Focused Exam: Cough, Danny Rivera Shadow health

 

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