Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data
Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data
Objective Data Collection: 15 of 15 (100.0%)
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
Lesion
Sclera (1/4 point)
White
Yellow tint
Redness
ORDER SHADOW HEALTH HELP HERE
Conjunctiva (1/4 point)
Moist and pink
Dry appearance
Redness
Swelling
Conjunctival Discharge (1/4 point)
No discharge
Clear, watery discharge
Purulent discharge
Inspected nasal cavities
1 of 1 point
Color (1/4 point) – Focused Exam: Cough – Danny Rivera Shadow health Objective & Subjective Data
Pink
Red
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
0.8 of 1 point
Right: Auditory Canal Color (No point)
Pink
Red
Pallor
Right: Tympanic Membrane Color (No point)
Pearly gray
Red
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
Red
Pallor
Left: Tympanic Membrane Color (1/10 point)
Pearly gray
Red
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
Redness
Tonsils (1/5 point)
No visible abnormal findings
Swelling
Redness
Throat Color (1/5 point)
Pink
Red
Throat 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
Barrel chest
Intercostal retraction while breathing
Excessive use of accessory muscles while breathing
Skin growths (freckles or moles)
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
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
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
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
Head And Neck (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
Palpated fremitus
1 of 1 point
Symmetry (1/2 point)
Equal bilaterally
Unequal bilaterally
Vibration (1/2 point)
Expected fremitus
Decreased fremitus
Palpated chest expansion
1 of 1 point
Symmetry (1/1 point)
Equal bilaterally
Unequal bilaterally
Subjective Data Collection: 22 of 22 (100.0%)
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Chief Complaint
