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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