Objective Data Collection: 23 of 23 (100%)
Correct
Partially correct
Incorrect
Missed
Inspected chest
1 of 1 point
Symmetry
(1/2 point)
Symmetric
Asymmetric
Appearance
(1/2 point)
No visible abnormal findings
Prominent pulsation
Abnormal apical impulse
Heaves or lifts
Inspected for jugular venous distention
1 of 1 point
Height Of Venous Pressure
(1/1 point)
4 cm or less above the sternal angle
More than 4 cm above the sternal angle
Inspected hands and fingernails
1 of 1 point
Right: Nail Changes
(1/3 point)
No visible abnormal findings
Pallor
Cyanosis
Splinter hemorrhages
Clubbing
Left: Nail Changes
(1/3 point)
No visible abnormal findings
Pallor
Cyanosis
Splinter hemorrhages
Clubbing
Capillary Refill Time
(1/3 point)
3 seconds or less
Greater than 3 seconds
Inspected lower extremities and toenails
1 of 1 point
Right: Edema
(1/9 point)
No edema
Pitting
Non-pitting
Right: Severity Of Edema
(1/9 point)
No edema
1+ Slight pitting
2+ Deeper pit, disappears in 10 to 15 seconds
3+ Noticeably deep pit that lasts more than a minute
4+ Very deep pit that lasts 2 to 5 minutes
Right: Appearance
(1/9 point)
No visible abnormal findings
Visible distortion or swelling
Discoloration
Skin thickening
Ulceration
Varicose veins
Right: Nail Changes
(1/9 point)
No visible abnormal findings
Pallor
Cyanosis
Splinter hemorrhages
Clubbing
Left: Edema
(1/9 point)
No edema
Pitting
Non-pitting
Left: Severity Of Edema
(1/9 point)
No edema
1+ Slight pitting
2+ Deeper pit, disappears in 10 to 15 seconds
3+ Noticeably deep pit that lasts more than a minute
4+ Very deep pit that lasts 2 to 5 minutes
Left: Appearance
(1/9 point)
No visible abnormal findings
Visible distortion or swelling
Discoloration
Skin thickening
Ulceration
Varicose veins
Left: Nail Changes
(1/9 point)
No visible abnormal findings
Pallor
Cyanosis
Splinter hemorrhages
Clubbing
Capillary Refill Time
(1/9 point)
3 seconds or less
Greater than 3 seconds
Palpated temporal arteries
1 of 1 point
Right: Vibration
(1/4 point)
No thrill
Thrill
Right: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration
(1/4 point)
No thrill
Thrill
Left: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Palpated carotid arteries
1 of 1 point
Right: Vibration
(1/4 point)
No thrill
Thrill
Right: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration
(1/4 point)
No thrill
Thrill
Left: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Palpated PMI
1 of 1 point
Location
(1/3 point)
Present at midclavicular line and 5th intercostal space
Displaced laterally
Amplitude
(1/3 point)
Brisk and tapping
Increased amplitude (hyperkinetic)
Diameter
(1/3 point)
Less than 3 cm
Greater than 3 cm
Palpated radial arteries
1 of 1 point
Right: Vibration
(1/4 point)
No thrill
Thrill
Right: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration
(1/4 point)
No thrill
Thrill
Left: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Palpated brachial arteries
1 of 1 point
Right: Vibration
(1/4 point)
No thrill
Thrill
Right: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration
(1/4 point)
No thrill
Thrill
Left: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Palpated femoral arteries
1 of 1 point
Right: Vibration
(1/4 point)
No thrill
Thrill
Right: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration
(1/4 point)
No thrill
Thrill
Left: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Palpated popliteal arteries
1 of 1 point
Right: Vibration
(1/4 point)
No thrill
Thrill
Right: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration
(1/4 point)
No thrill
Thrill
Left: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Palpated tibial arteries
1 of 1 point
Right: Vibration
(1/4 point)
No thrill
Thrill
Right: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration
(1/4 point)
No thrill
Thrill
Left: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Palpated dorsalis pedis arteries
1 of 1 point
Right: Vibration
(1/4 point)
No thrill
Thrill
Right: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration
(1/4 point)
No thrill
Thrill
Left: Amplitude
(1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Auscultated temporal arteries
1 of 1 point
Right
(1/2 point)
No bruit
Bruit
Left
(1/2 point)
No bruit
Bruit
Auscultated carotid arteries
1 of 1 point
Right
(1/2 point)
No bruit
Bruit
Left
(1/2 point)
No bruit
Bruit
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 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
Auscultated abdominal aorta
1 of 1 point
Sounds
(1/1 point)
No bruit
Bruit
Auscultated renal arteries
1 of 1 point
Right
(1/2 point)
No bruit
Bruit
Left
(1/2 point)
No bruit
Bruit
Auscultated iliac arteries
1 of 1 point
Right
(1/2 point)
No bruit
Bruit
Left
(1/2 point)
No bruit
Bruit
Auscultated femoral arteries
1 of 1 point
Right
(1/2 point)
No bruit
Bruit
Left
(1/2 point)
No bruit
Bruit
Performed ankle-brachial index test
1 of 1 point
Abi
(1/1 point)
> 1.40 (noncompressable)
1.00 – 1.40 (normal)
0.90 – 0.99 (borderline ischemia)
< 0.90 (abnormal) Performed EKG 1 of 1 point Sinus Rhythm (1/2 point) Regular Irregular St Changes (1/2 point) No ST changes ST changes present
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