Danny Rivera Pediatric Cough Shadow Health Assessment Objective Data

Danny Rivera Pediatric Cough Shadow Health Assessment Objective Data

Objective Data Collection: 12.4 of 13 (95.38%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed
 Inspected eyes and orbital area
1 of 1 point
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
  • Danny Rivera Pediatric Cough Shadow Health Assessment Objective Data
 Inspected nasal cavities
1 of 1 point
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
0.8 of 1 point
Right: Auditory Canal Color (No point)
  •  Pink
  •  Erythemic
  •  Pallor
Right: Tympanic Membrane Color (No point)
  •  Pearly gray
  •  Erythemic
  •  Opaque
  •  Yellow
  •  Not visible because of cerumen
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
0.6 of 1 point
Oral Mucosa (1/5 point)
  •  Moist and pink
  •  Dry appearance
  •  Erythema
Tonsils (No point)
  •  No visible abnormal findings
  •  Edema
  •  Erythema
Posterior Oropharynx Color (No 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
1 of 1 point
 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)
 Palpated sinuses
1 of 1 point
 Palpated lymph nodes
1 of 1 point
 Palpated fremitus
1 of 1 point
 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
  • Danny Rivera Pediatric Cough Shadow Health Assessment Objective Data
 Auscultated for bronchophony
1 of 1 point
 Auscultated heart sounds
1 of 1 point
 Percussed chest wall
1 of 1 point
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
  • Danny Rivera Pediatric Cough Shadow Health Assessment Objective Data
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