Focused Exam: Cough, Danny Rivera Shadow health

•  No visible abnormal findings
•  Ptosis
•  Eyelid edema
•  Lesion
•  Allergic shiners
• Focused Exam: Cough, Danny Rivera Shadow health

•  White
•  Jaundice
•  Injection
•  Icterus

•  Moist and pink
•  Pale
•  Dry appearance
•  Erythema
•  Edema

•  No discharge
•  Clear, watery discharge
•  Purulent discharge
• Focused Exam: Cough, Danny Rivera Shadow health

•  Pink
•  Erythemic
•  Bluish

•  No discharge
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

•  Patent
•  Decreased patency
•  Not patent

•  No additional visible abnormal findings
•  Foreign body present
•  Polyp
•  Septum perforated
•  Septum deviated
•  Lesion

•  Pink
•  Erythemic
•  Pallor

•  Pearly gray
•  Erythemic
•  Opaque
•  Yellow
•  Not visible because of cerumen

•  No visible abnormal findings
•  Fluid observed
•  Visible scars
•  Bulging
•  Perforation
•  Retraction

•  5:00
•  Cone of light distorted

•  No discharge
•  Cerumen
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

•  Pink
•  Erythemic
•  Pallor

•  Pearly gray
•  Erythemic
•  Opaque
•  Yellow
•  Not visible because of cerumen

•  No visible abnormal findings
•  Fluid observed
•  Visible scars
•  Bulging
•  Perforation
•  Retraction

•  7:00
•  Cone of light distorted

•  No discharge
•  Cerumen
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

•  Moist and pink
•  Dry appearance
•  Erythema

•  No visible abnormal findings
•  Edema
•  Erythema

•  Pink
•  Erythemic

•  No abnormal findings
•  Cobblestoning
•  Exudate

•  No discharge
•  Clear discharge
•  Purulent discharge

•  Symmetric
•  Asymmetric

•  No visible abnormal findings
•  Swelling
•  Visible pulsation
•  Visible mass
•  Discoloration

•  Symmetric
•  Asymmetric

•  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)

•  None reported
•  Tenderness reported

•  None reported
•  Tenderness reported

•  No palpable nodes
•  Palpable nodes on right side
•  Palpable nodes on left side

•  No palpable nodes
•  Palpable nodes on right side
•  Palpable nodes on left side

•  No palpable nodes
•  Palpable nodes on right side
•  Palpable nodes on left side
• Focused Exam: Cough, Danny Rivera Shadow health

•  Equal bilaterally
•  Unequal bilaterally

•  Expected fremitus
•  Decreased fremitus

•  Present in all areas
•  Diminished in some areas
•  Absent in some areas

•  No adventitious sounds
•  Wheezing
•  Fine crackles
•  Stridor
•  Rhonchi
•  Rales

•  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

•  Positive
•  Negative

•  S1 and S2 audible
•  S1, S2, and S3 audible
•  S1, S2, and S4 audible
•  S1, S2, S3, and S4 audible

•  No extra sounds
•  Gallops
•  Murmur
•  Friction rub
•  Valve clicks

•  All areas resonant
•  Some areas dull, some resonant
•  Some areas hyperresonant, some resonant

•  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

Focused Examination: Cough, Danny Rivera Shadow Health

Objective Data Collection: 13 of 13 (100%)

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– Inspected Eyes and Orbital Area (1 point)
– Orbital Area: No visible abnormal findings
– Sclera: White
– Conjunctiva: Moist and pink
– Conjunctival Discharge: No discharge

– Inspected Nasal Cavities (1 point)
– Color: Pink
– Discharge: No discharge
– Turbinate Patency: Patent
– Observations: No additional visible abnormal findings

– Inspected Ears (1 point)
– Right:
– Auditory Canal Color: Pink
– Tympanic Membrane Color: Pearly gray
– Tympanic Membrane Appearance: No visible abnormal findings
– Cone Of Light: 5:00
– Discharge: No discharge
– Left:
– Auditory Canal Color: Pink
– Tympanic Membrane Color: Pearly gray
– Tympanic Membrane Appearance: No visible abnormal findings
– Cone Of Light: 7:00
– Discharge: No discharge

– Inspected Mouth and Throat (1 point)
– Oral Mucosa: Moist and pink
– Tonsils: No visible abnormal findings
– Posterior Oropharynx Color: Pink
– Posterior Oropharynx Texture: No abnormal findings
– Post Nasal Drip: No discharge

– Inspected Neck (1 point)
– Symmetry: Symmetric
– Appearance: No visible abnormal findings

– Inspected Chest (1 point)
– Symmetry: Symmetric
– Appearance: No visible abnormal findings

– Palpated Sinuses (1 point)
– Frontal: None reported
– Maxillary: None reported

– Palpated Lymph Nodes (1 point)
– Cervical: No palpable nodes
– Supraclavicular: No palpable nodes
– Axillary: No palpable nodes

– Palpated Fremitus (1 point)
– Symmetry: Equal bilaterally
– Vibration: Expected fremitus

– Auscultated Breath Sounds (1 point)
– Breath Sounds: Present in all areas
– Adventitious Sounds: No adventitious sounds
– Location: All areas clear

– Auscultated for Bronchophony (1 point)
– Bronchophony: Negative

– Auscultated Heart Sounds (1 point)
– Heart Sounds: S1 and S2 audible
– Extra Heart Sounds: No extra sounds

– Percussed Chest Wall (1 point)
– Observations: All areas resonant
– Location: No areas of dullness

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