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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