Focused Examination: Cough, Danny Rivera – Shadow Health

Focused Examination: Cough, Danny Rivera – Shadow Health

Objective Data Collection: 13 of 13 (100%)

Inspected Eyes and Orbital Area
– Orbital Area (1/4 point)
– 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

Inspected Nasal Cavities
– 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
– 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

Shawn Billings, a 28 year-old African American patient

– 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
– 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
– Symmetry (1/2 point)
– Symmetric
– Asymmetric

– Appearance (1/2 point)
– No visible abnormal findings
– Swelling
– Visible pulsation
– Visible mass
– Discoloration

Inspected Chest
– 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
– Frontal (1/2 point)
– None reported
– Tenderness reported

– Maxillary (1/2 point)
– None reported
– Tenderness reported

Palpated Lymph Nodes
– Cervical (1/3 point)
– No palpable nodes
– Palpable nodes on the right side
– Palpable nodes on the left side

– Supraclavicular (1/3 point)
– No palpable nodes
– Palpable nodes on the right side
– Palpable nodes on the left side

– Axillary (1/3 point)
– No palpable nodes
– Palpable nodes on the right side
– Palpable nodes on the left side

Palpated Fremitus
– Symmetry (1/2 point)
– Equal bilaterally
– Unequal bilaterally

– Vibration (1/2 point)
– Expected fremitus
– Decreased fremitus

Auscultated Breath Sounds
– 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
– Bronchophony (1/1 point)
– Positive
– Negative

Auscultated Heart Sounds
– 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
– 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