Focused Exam Chest Pain Objective Data

Focused Exam: Chest Pain Results Your Results Overview Objective Data Collection: 21 of 21 (100%) Transcript Subjective Data Collection Objective Data Collection Correct Incorrect Partially correct Missed Education & Empathy Inspected face 1 of 1 point Documentation Care Plan Program Competency Progress 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 Symmetry (1/2 point) Symmetric Asymmetric 1 of 1 point 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 Right: Appearance (1/4 point) 1 of 1 point Left: Appearance (1/4 point) No visible abnormal findings No visible abnormal findings Redness Redness Moles or skin tags Moles or skin tags Masses (warts, cysts, or tumors) Masses (warts, cysts, or tumors) Freckles, birthmark, or other discoloration Freckles, birthmark, or other discoloration Excessive dry or flaking skin Excessive dry or flaking skin Purpura Purpura Scarring Scarring Laceration, lesion, or wound Laceration, lesion, or wound Bruising Bruising Rash Right: Nail Changes (1/4 point) Rash Left: Nail Changes (1/4 point) No visible abnormal findings No visible abnormal findings Pallor Pallor Cyanosis Cyanosis Splinter hemorrhages Splinter hemorrhages Clubbing Clubbing Inspected lower extremities and toenails Right: Appearance (1/4 point) 1 of 1 point Right: Nail Changes (1/4 point) No visible abnormal findings No visible abnormal findings Visible distortion or swelling Pallor Brownish pigmentation Cyanosis Skin thickening Splinter hemorrhages Ulceration Clubbing Varicose veins Left: Appearance (1/4 point) Left: Nail Changes (1/4 point) No visible abnormal findings No visible abnormal findings Visible distortion or swelling Pallor Brownish pigmentation Cyanosis Skin thickening Splinter hemorrhages Ulceration Clubbing Varicose veins Inspect lower extremities for edema Right: Edema (1/4 point) 1 of 1 point Right: Severity Of Edema (1/4 point) No edema No edema Pitting 1+ Slight pitting Non-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) Left: Severity Of Edema (1/4 point) No edema No edema Pitting 1+ Slight pitting Non-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 Fingers (1/2 point) 1 of 1 point Toes (1/2 point) Less than 3 seconds Less than 3 seconds Greater than 3 seconds Greater than 3 seconds Palpated carotid arteries Right: Vibration (1/4 point) 1 of 1 point Right: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Left: Vibration (1/4 point) Left: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Palpated PMI Location (1/3 point) 1 of 1 point Diameter (1/3 point) Present at midclavicular line and 5th intercostal space Less than 3 cm Displaced laterally Greater than 3 cm Amplitude (1/3 point) Brisk and tapping Increased amplitude (hyperkinetic) Palpated brachial arteries Right: Vibration (1/4 point) 1 of 1 point Right: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Left: Vibration (1/4 point) Left: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Palpated radial arteries Right: Vibration (1/4 point) 1 of 1 point Right: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Left: Vibration (1/4 point) Left: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Palpated femoral arteries Right: Vibration (1/4 point) 1 of 1 point Right: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Left: Vibration (1/4 point) Left: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Palpated popliteal arteries Right: Vibration (1/4 point) 1 of 1 point Right: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Left: Vibration (1/4 point) Left: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Palpated tibial arteries Right: Vibration (1/4 point) 1 of 1 point Right: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Left: Vibration (1/4 point) Left: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Palpated dorsalis pedis arteries Right: Vibration (1/4 point) 1 of 1 point Right: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Left: Vibration (1/4 point) Left: Amplitude (1/4 point) No thrill 0 Absent Thrill 1+ Diminished or barely palpable 2+ Expected 3+ Increased 4+ Bounding pulse Auscultated carotid arteries Right (1/2 point) 1 of 1 point Left (1/2 point) No bruit No bruit Bruit Bruit Auscultated heart sounds 1 of 1 point Heart Sounds (1/2 point) Extra Heart Sounds (1/2 point) S1 and S2 audible No extra sounds S1, S2, and S3 audible Gallops S1, S2, and S4 audible Murmur S1, S2, S3, and S4 audible Friction rub Valve clicks Auscultated abdominal aorta 1 of 1 point Sounds (1/1 point) No bruit Bruit Auscultated abdominal and lower extremity arteries Right: Renal (1/6 point) No bruit Bruit Right: Femoral (1/6 point) No bruit Bruit Left: Iliac (1/6 point) 1 of 1 point Right: Iliac (1/6 point) No bruit Bruit Left: Renal (1/6 point) No bruit Bruit Left: Femoral (1/6 point) No bruit No bruit Bruit Bruit Auscultated breath sounds Breath Sounds (1/3 point) 1 of 1 point Adventitious Sounds (1/3 point) Present in all areas No adventitious sounds Diminished in some areas Wheezing Absent in some areas 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 Sinus Rhythm (1/2 point) Comments 1 of 1 point St Changes (1/2 point) Regular No ST elevation Irregular ST elevation present