Shadow Health. Focused Exam Chest Pain Brian Foster 2018. 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.

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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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