*NURSING > SHADOW HEALTH > Shadow Health. Focused Exam Chest Pain Brian Foster 2018. Experience Overview FOCUSED EXAM: CHEST PA (All)
Experience Overview FOCUSED EXAM: CHEST PAIN Patient: Brian Foster Grade: 100% Subjective Data Collection 23 out of 23 Objective Data Collection 21 out of 21 Time 183 minutes total spent in a... ssignment Objective Data Collection: 21 of 21 (100%) Inspected face 1 of 1 point Appearance (1/1 point) No visible abnormal findings Rash or lesion Cyanosis Pallor Redness or flushing Evidence of trauma (scar, laceration, or bruising) Inspected for jugular venous distension 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 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) Inspected hands and fingernails 1 of 1 point Right: Appearance (1/4 point) No visible abnormal findings Redness Moles or skin tags Masses (warts, cysts, or tumors) Freckles, birthmark, or other discoloration Excessive dry or flaking skin Purpura Scarring Laceration, lesion, or wound Bruising Rash Left: Appearance (1/4 point) No visible abnormal findings Redness Moles or skin tags Masses (warts, cysts, or tumors) Freckles, birthmark, or other discoloration Excessive dry or flaking skin Purpura Scarring Laceration, lesion, or wound Bruising Rash Right: Nail Changes (1/4 point) No visible abnormal findings Pallor Cyanosis Splinter hemorrhages Clubbing Left: Nail Changes (1/4 point) No visible abnormal findings Pallor Cyanosis Splinter hemorrhages Clubbing Inspected lower extremities and toenails 1 of 1 point Right: Appearance (1/4 point) No visible abnormal findings Visible distortion or swelling Brownish pigmentation Skin thickening Ulceration Varicose veins Right: Nail Changes (1/4 point) No visible abnormal findings Pallor Cyanosis Splinter hemorrhages Clubbing Left: Appearance (1/4 point) No visible abnormal findings Visible distortion or swelling Brownish pigmentation Skin thickening Ulceration Varicose veins Left: Nail Changes (1/4 point) No visible abnormal findings Pallor Cyanosis Splinter hemorrhages Clubbing Inspect lower extremities for edema 1 of 1 point Right: Edema (1/4 point) No edema Pitting Non-pitting Right: Severity Of Edema (1/4 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: Edema (1/4 point) No edema Pitting Non-pitting Left: Severity Of Edema (1/4 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 Tested capillary refill time 1 of 1 point Fingers (1/2 point) Less than 3 seconds Greater than 3 seconds Toes (1/2 point) Less than 3 seconds Greater than 3 seconds 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 PMI1 of 1 point Location (1/3 point) Present at midclavicular line and 5th intercostal space Displaced laterally Diameter (1/3 point) Less than 3 cm Greater than 3 cm Amplitude (1/3 point) Brisk and tapping Increased amplitude (hyperkinetic) 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 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 pulseLeft: 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 carotid arteries 1 of 1 point Right (1/2 point) No bruit Bruit Left (1/2 point) No bruit Bruit 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 abdominal and lower extremity arteries 1 of 1 point Right: Renal (1/6 point) No bruit Bruit Right: Iliac (1/6 point) No bruit BruitRight: Femoral (1/6 point) No bruit Bruit Left: Renal (1/6 point) No bruit Bruit Left: Iliac (1/6 point) No bruit Bruit Left: Femoral (1/6 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 Performed EKG 1 of 1 point Sinus Rhythm (1/2 point) Regular Irregular St Changes (1/2 point) No ST elevation ST elevation present Subjective Data Collection: 23 of 23 (100.0%) A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. ********************************** CONTINUED IN THE ATTACHMENT *********************************** [Show More]
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