Danny Rivera Pediatric Cough Shadow Health Assessment Objective Data

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Danny Rivera Pediatric Cough Shadow Health Assessment Objective Data

Objective Data Collection: 12.4 of 13 (95.38%)

 Correct

 Partially correct

 Incorrect

 Missed

 Inspected eyes and orbital area

1 of 1 point

Orbital Area 
(1/4 point)

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 No visible abnormal findings

 Ptosis

 Eyelid edema

 Lesion

 Allergic shiners

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

Danny Rivera Pediatric Cough Shadow Health Assessment Objective Data

 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

0.8 of 1 point

Right: Auditory Canal Color 
(No point)

 Pink

 Erythemic

 Pallor

Right: Tympanic Membrane Color 
(No 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

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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

0.6 of 1 point

Oral Mucosa 
(1/5 point)

 Moist and pink

 Dry appearance

 Erythema

Tonsils 
(No point)

 No visible abnormal findings

 Edema

 Erythema

Posterior Oropharynx Color 
(No 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

 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

 Palpated lymph nodes

1 of 1 point

 Palpated fremitus

1 of 1 point

 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

Danny Rivera Pediatric Cough Shadow Health Assessment Objective Data

 Auscultated for bronchophony

1 of 1 point

 Auscultated heart sounds

1 of 1 point

 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

Danny Rivera Pediatric Cough Shadow Health Assessment Objective Data

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