Objective Data Collection: 6 of 6 (100.0%)
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
Rash or lesion
AP diameter abnormal
Intercostal retraction while breathing
Excessive use of accessory muscles while breathing
Pectus excavatum
Evidence of trauma (scar, laceration, or bruising)
Palpated chest expansion
1 of 1 point
Symmetry
(1/1 point)
Equal bilaterally
Unequal bilaterally
Palpated tactile fremitus
1 of 1 point
Symmetry
(1/2 point)
Equal bilaterally
Unequal bilaterally
Vibration
(1/2 point)
Expected fremitus
Decreased fremitus
Absent fremitus
Percussed chest wall
1 of 1 point
Observations
(1/2 point)
All areas resonant
Some areas of dullness
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
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
Leave a Reply