Objective Data – Brian foster chest pain shadow health assessment

Objective Data – Brian foster chest pain shadow health assessment

Objective Data – Brian foster chest pain shadow health assessment
Objective Data Collection: 30 of 33 (90.91%)

 Correct
 Partially correct

 Incorrect
 Missed

 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)
Objective Data – Brian foster chest pain shadow health assessment

 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

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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)
Objective Data – Brian foster chest pain shadow health assessment

 Inspected abdomen
0.67 of 1 point

Symmetry (1/3 point)

 Symmetric
 Asymmetric

Contour (No point)

 Flat
 Rounded
 Protuberant
 Hollowed

Appearance (1/3 point)

 No visible abnormal findings
 Rash
 Striae
 Bulging around umbilicus
 Distension
 Visible masses (warts, cysts, or tumors)
 Freckles, birthmark, or discoloration
 Excessive hair growth
 Visible scars
 Laceration, lesion or wound
 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

Right: Nail Changes (1/4 point)

 No visible abnormal findings
 Pallor
 Cyanosis
 Splinter hemorrhages
 Clubbing

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

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
Objective Data – Brian foster chest pain shadow health assessment

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

 Auscultated carotid arteries
0.5 of 1 point

Right (No point)

 No bruit
 Bruit

Left (1/2 point)

 No bruit
 Bruit

 Auscultated heart sounds
0.5 of 1 point

Heart Sounds (No 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 breath sounds
0.33 of 1 point

Breath Sounds (1/3 point)

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

Adventitious Sounds (No point)

 No adventitious sounds
 Wheezing
 Fine crackles
 Stridor
 Rhonchi
 Course crackles

Location (No 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
Objective Data – Brian foster chest pain shadow health assessment

 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

Left: Renal (1/6 point)

 No bruit
 Bruit

Right: Iliac (1/6 point)

 No bruit
 Bruit

Left: Iliac (1/6 point)

 No bruit
 Bruit

Right: Femoral (1/6 point)

 No bruit
 Bruit

Left: Femoral (1/6 point)

 No bruit
 Bruit

 Auscultated bowel sounds
1 of 1 point

Bowel Sounds (1/2 point)

 Absent
 Hypoactive
 Normoactive
 Hyperactive

Location Of Non Normoactive Bowel Sounds (1/2 point)

 All quadrants normoactive
 Right upper quadrant
 Right lower quadrant
 Left upper quadrant
 Left lower quadrant

 Palpated carotid arteries
0.5 of 1 point

Right: Vibration (No point)

 No thrill
 Thrill

Right: Amplitude (No 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 PMI
1 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 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 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
0.5 of 1 point

Right: Vibration (1/4 point)

 No thrill
 Thrill

Right: Amplitude (No 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 (No 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

 Palpated abdomen – light
1 of 1 point

Tenderness (1/3 point)

 None reported
 Tenderness reported

Location Of Tenderness (1/3 point)

 No quadrants tender
 Right upper quadrant
 Right lower quadrant
 Left upper quadrant
 Left lower quadrant

Observations (1/3 point)

 No additional observations
 Masses
 Guarding
 Distension
 Muscle resistance
 Rigidity

 Palpated abdomen – deep
1 of 1 point

Presence Of Unexpected Mass (1/2 point)

 No palpable mass
 Palpable mass

Location Of Mass (1/2 point)

 No palpable mass
 Right upper quadrant
 Right lower quadrant
 Left upper quadrant
 Left lower quadrant
 Around umbilicus

 Palpated liver
1 of 1 point

Detection (1/1 point)

 Not palpable
 Palpable

 Palpated spleen
1 of 1 point

Detection (1/1 point)

 Not palpable
 Palpable

 Palpated kidneys
1 of 1 point

Right (1/2 point)

 Not palpable
 Palpable

Left (1/2 point)

 Not palpable
 Palpable

 Tested skin turgor
1 of 1 point

Observations (1/1 point)

 No tenting
 Tenting

 Auscultated organs
1 of 1 point

Liver (1/2 point)

 No friction rub
 Audible friction rub

Spleen (1/2 point)

 No friction rub
 Audible friction rub

 Percussed abdomen
1 of 1 point

Observations (1/1 point)

 All areas generally tympanic
 Some areas dull, some tympanic
 Some areas resonant
Objective Data – Brian foster chest pain shadow health assessment

 Percussed spleen
1 of 1 point

Spleen (1/1 point)

 Tympany
 Dullness

 Percussed liver
1 of 1 point

Liver Span (1/1 point)

 Smaller than 6 cm
 Between 6 and 12 cm
 Greater than 12 cm

 Performed EKG
1 of 1 point

Sinus Rhythm (1/2 point)

 Regular
 Irregular

St Changes (1/2 point)

 No ST elevation
 ST elevation present
Objective Data – Brian foster chest pain shadow health assessment