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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