NURS 6512 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System

Sample Answer for NURS 6512 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System Included After Question

DCE FOCUSED EXAM: CHEST PAIN ASSIGNMENT:

Complete the following in Shadow Health:

  • Cardiovascular Concept Lab (Required)
  • Respiratory(Recommended but not required)
  • Cardiovascular (Recommended but not required)
  • Episodic/Focused Note for Focused Exam (Required): Chest Pain

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 7 Day 7 deadline.

A Sample Answer For the Assignment: NURS 6512 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System

Title: NURS 6512 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System

Shadow Health Digital Clinical Experience Focused Exam: Chest Pain Documentation

Name: Mr. J.M. Age: 38 years Sex: Male

SUBJECTIVE DATA:

Chief Complaint (CC): “I have sporadic chest pain”

History of Present Illness (HPI): Mr. J.M. is a 38-year-old African American male who presented to the emergency department with complaints of sporadic chest pain for the last one month. The pain is usually centrally located and radiates to the left arm. He has experienced 3 episodes since the last month with each episode lasting several minutes. Currently, the pain is at 0 on a scale of zero to 10 although it is generally at 5 at its worst. The pain is characteristically uncomfortable and tight. It is aggravated by activities such as climbing stairs and yardwork while brief episodes of rest relieve the pain. He has not taken any medications for the pain.

Medications: Reports taking Lopressor 100mg PO once daily for hypertension and Lipitor 20mg PO once daily for hyperlipidemia as well as fish oil 1000mg PO twice daily.

Allergies: None

Past Medical History (PMH): Reports hypertension and hypercholesterolemia. No previous hospitalizations or blood transfusions. Denies prior chest pain treatment. Poor blood pressure monitoring both at home. Denies regular blood pressure checks at the pharmacy and drug store. Reports a recent EKG test that was normal. His last visit to a healthcare provider was three months ago.

Past Surgical History (PSH): No previous surgeries.

Sexual/Reproductive History: Heterosexual.

Personal/Social History: Has lived a relatively stress-free lifestyle. Regular water intake of about a liter per day. Drinks 2 cups of coffee daily. Denies routine regular physical activity and his last regular exercise was 2 years ago. Reports moderate alcohol consumption of about 2 to 3 drinks per week mostly on weekends but no tobacco or illicit drug use. His typical breakfast is a granola bar and instant breakfast shake, lunch turkey sub, and his dinner is typically grilled meat alongside vegetables. 

Immunization History: All immunization up to date. The last COVID-19 vaccine was February this year, the last Tdap was May 2022 and the last influenza was January 2022.

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Significant Family History: His mother is 65 years old and hypertensive while the father is 70 years old and obese. The grandmother died at 77 years due to a heart attack while the grandfather is 85 but suffered a stroke at 80 years. He has two daughters all alive and well.

Review of Systems:

General: Denies fever, changes in weight, chills, fatigue, night sweats, and palpitations.

            Cardiovascular/Peripheral Vascular: No edema, easy bruising, angina, or easy bleeding.

            Respiratory: No difficulty in bleeding, sputum, cough, or shortness of breath.

            Gastrointestinal: Denies alteration in bowel habits, abdominal pain and nausea, and vomiting

            Musculoskeletal: No back pains, joint pains, and muscle weakness.

            Psychiatric: No anxiety, depression, delusions, or hallucinations

OBJECTIVE DATA:

            Physical Exam:

Vital signs: Temperature- 98.5 F, pulse 80 beats per min, respiratory rate- 19 breaths per minute, blood pressure- 132/86 mmHg, saturation- 92% on room air, height 70. 86 inches, weight 251 lbs. BMI- 29.

NURS 6512 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System
NURS 6512 Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System

General: A young African American male, well kempt and groomed, and appropriate for his stated age. Not in any obvious distress, good body built and well hydrated. No pallor, finger clubbing, splinter hemorrhages, jaundice, cyanosis, lymphadenopathy, or peripheral edema.

              Cardiovascular/Peripheral Vascular: Nondistended neck veins (JVP less than 4cm above sternal angle), right carotid pulse 3+ with a thrill and bruit, left carotid pulse 2+ with no thrill or bruit, right and left brachial and radial arteries pulses 2+ with no thrills, right and left femoral arteries pulses 2+ with no thrills and bruits, right and left popliteal arteries pulses 1+ with no thrills, right and left tibial and dorsalis pedis pulses 1+ with no thrills, no renal, iliac and abdominal aorta bruits, and capillary refill is less than 3 seconds in all the digits. Precordium is brisk and tapping. The point of maximal impulse is displaced laterally and less than 3 cm, with a heave but no thrill. S1, S2, and S3 were heard with gallops, no murmurs.

Respiratory: Symmetric chest, moves with respiration with no obvious scars or masses on inspection. the trachea is central, with equal chest expansion, no tenderness or palpable masses, and equal tactile fremitus on palpation. Resonant on percussion. Good air entry and vesicular breath sounds in all lung zones, and no wheezes or rhonchi on auscultation.

Gastrointestinal: Nondistended, moves with respiration, symmetric, normal contour and fullness, umbilicus everted and no visible distended veins, striae, or scars. No tenderness or palpable masses on light and deep palpation. The liver is palpable 2 cm below the right costal margin. Liver span 8 cm. Spleen and both kidneys are impalpable. Tympanic on percussion, no shifting dullness or fluid thrill. No friction rubs over the liver and spleen.

Musculoskeletal: Normal muscle bulk, power of 5/5 in all muscle groups, normal reflexes, and range of movement across all joints.

Neurological: GCS 15/15, oriented to time place, and person, all cranial nerves and sensation intact, no neurological deficits noted, good bladder and bowel function.

Skin: No rashes, darkening, tenting, or nail changes.

Diagnostic Test/Labs: An EKG was done which revealed a sinus rhythm with no ST changes. Other critical tests include cardiac biomarkers particularly, troponin T/I, CK-MB, and myoglobin to exclude myocardial injury (Harskamp et al., 2019). Lipid profile and random blood sugar are required to check the level of lipid control and exclude diabetes mellitus respectively. Additionally, LDH to assess for cell necrosis, BNP to exclude concurrent heart failure, and inflammatory markers especially CRP for prognostication. Similarly, complete blood count with differential, urea creatinine, and electrolytes as well as liver function tests are required as a baseline for medication. Imaging tests include a transthoracic echocardiogram to assess left ventricular function, detect any wall motion abnormalities and identify any complications (Harskamp et al., 2019). Finally, a cardiac CT with IV contrast may be required to rule out differentials such as pulmonary embolism and aortic dissection.

ASSESSMENT:

Mr. J.M. is a 38-year-old African American male, known patient with hyperlipidemia and hypertension who presents with complaints of sporadic centrally located chest pain that radiates to the left arm. The pain is usually aggravated by exertion but relieved by rest with a history of physical inactivity. On examination, the right carotid artery pulse is increased with a bruit and thrill, the apex is displaced laterally, and S1, S2, and S3 are heard with gallops but no murmurs.

Main Diagnosis- The primary diagnosis is stable angina. Mr. J.M. presents with retrosternal chest pain that is tight and uncomfortable and that radiates to the left arm. This is characteristic of angina. However, these symptoms are worsened by exertion but relieved by rest which is a distinct feature of stable angina (Rousan & Thadani, 2019). According to Rousan and Thadani (2019), atherosclerosis is the most common etiology of this condition. Mr. J.M. has classic risk factors for atherosclerosis including arterial hypertension, hyperlipidemia, alcohol consumption, and overweight as well as a family history of cardiovascular events.

Differential diagnosis

Non-ST segmented elevated myocardial infarction- Myocardial infarction refers to an acute myocardial injury caused ischemia that results in tissue necrosis. This condition also presents with a retrosternal chest pain that dull and tight, precipitated by exertion and radiates to the left arm, shoulder, neck or jaw. Myocardial infarction may also be precipitated by an atherosclerotic event. However, lack of ST changes on EKG suggests NSTEMI (Cohen & Visveswaran, 2020).

Hypertension and hyperlipidemia- Mr. J.M. has previous history of hypertension on metoprolol and hyperlipidemia on Lipitor. Furthermore, lateral displacement of the apex beat as well as a heave suggest left ventricular hypertrophy which is usually a consequence of arterial hypertension (Oparil et al., 2018).

References

Cohen, M., & Visveswaran, G. (2020). Defining and managing patients with non-ST-elevation myocardial infarction: Sorting through type 1 vs other types. Clinical Cardiology43(3), 242–250. https://doi.org/10.1002/clc.23308

Harskamp, R. E., Laeven, S. C., Himmelreich, J. C., Lucassen, W. A. M., & van Weert, H. C. P. M. (2019). Chest pain in general practice: a systematic review of prediction rules. BMJ Open9(2), e027081. https://doi.org/10.1136/bmjopen-2018-027081

Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018). Hypertension. Nature Reviews. Disease Primers4(1), 18014. https://doi.org/10.1038/nrdp.2018.14

Rousan, T. A., & Thadani, U. (2019). Stable angina medical therapy management guidelines: A critical review of guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence. European Cardiology14(1), 18–22. https://doi.org/10.15420/ecr.2018.26.1

Subjective Data Collection: 30 of 30 (100.0%)

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

  • Found: Indicates an item that you found.
  • Available: Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

  • Finding: Established chief complaint
  • Finding: Reports chest pain (Found) Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: Do you have chest pain?

History of Present Illness

  • Finding: Asked about onset of pain
  • Finding: Reports chest pain started appearing in the past month (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: When did your chest pain start?
  • Finding: Asked about location of pain
  • Finding: Reports pain is in center of the chest (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Where is the pain?
  • Finding: Reports pain does not radiate (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does the pain radiate?
  • Finding: Denies arm pain (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you experiencing arm pain?
  • Finding: Denies shoulder pain (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you experiencing shoulder pain?
  • Finding: Denies back pain (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you experiencing back pain?
  • Finding: Denies neck pain (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you experiencing neck pain?
  • Finding: Asked about duration of pain episodes
  • Finding: Reports each pain episode lasted “several” minutes (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How long does your chest pain last?
  • Finding: Asked about frequency of pain
  • Finding: Reports 3 pain episodes in past month (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How many times in the last month have you had chest pain?
  • Finding: Reports that pain episodes did not seem related (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Did the episodes seem associated?
  • Finding: Asked about severity of pain
  • Finding: Reports current pain is 0 out of 10 (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How would you rate your pain on a scale of zero to ten?
  • Finding: Reports pain severity at its worst is 5 out of 10 (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How would you rate your pain on a scale of zero to ten?
  • Finding: Asked about characteristics of pain
  • Finding: Describes pain as tight and uncomfortable (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Can you describe your pain?
  • Finding: Denies crushing pain (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is the pain crushing?
  • Finding: Denies gnawing pain (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is the pain gnawing?
  • Finding: Denies burning pain (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is the pain burning?
  • Finding: Asked about aggravating factors
  • Finding: Reports pain is aggravated by activity (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What makes the pain worse?
  • Finding: Reports pain occurred with yard work and taking stairs (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What activity triggered the pain?
  • Finding: Reports pain does not worsen with eating (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is the pain worse when you eat?
  • Finding: Reports pain does not worsen after spicy foods (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is the pain worse after you eat spicy food?
  • Finding: Reports pain does not worsen after high-fat foods (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is the pain worse after you eat high-fat foods?
  • Finding: Asked about relieving factors
  • Finding: Reports pain relief with brief period of rest (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What relieves your pain?
  • Finding: Denies taking medication to treat chest pain (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Did you take anything for the chest pain?

Past Medical History

  • Finding: Confirmed allergies
  • Finding: Confirms allergies (Found) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have new allergies?
  • Finding: Asked about related medical conditions
  • Finding: Denies angina diagnosis (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have a history of angina?
  • Finding: Reports high blood pressure (Found) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have high blood pressure?
  • Finding: Reports high cholesterol (Found) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have high cholesterol?
  • Finding: Denies coronary artery disease (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have coronary artery disease?
  • Finding: Denies diabetes (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have diabetes?
  • Finding: Denies previous treatment for chest pain (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you had previous treatment for chest pain?
  • Finding: Asked about blood pressure monitoring
  • Finding: Does not frequently monitor BP at home (Found) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: How often do you measure your blood pressure?
  • Finding: Reports infrequent BP checks (Found) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: When do you measure your blood pressure?
  • Finding: Denies knowledge of typical BP reading (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What is your typical blood pressure reading?
  • Finding: Asked about past cardiac tests
  • Finding: Reports recent EKG test (Found) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you recently had an EKG?
  • Finding: Reports annual stress test (Found) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you recently had a stress test?
  • Finding: Followed up on results of cardiac tests

Finding: Reports belief that EKG was normal (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What were the results of your last EKG?

Finding: Reports belief that stress test was normal (Found) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What were the results of your last stress test?

Home Medications

  • Finding: Asked about home medications
  • Finding: Reports taking high blood pressure medication (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Do you take medication for high blood pressure?
  • Finding: Reports taking high cholesterol medication (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Do you take medication for high cholesterol?
  • Finding: Reports occasional ibuprofen use (Available) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Do you take over the counter medications?
  • Finding: Reports taking fish oil (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Do you take any supplements?
  • Finding: Denies aspirin regimen (Available) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Do you take aspirin?
  • Finding: Followed up on high blood pressure medication
  • Finding: Reports taking lisinopril (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: What medication do you take for high blood pressure?
  • Finding: Reports lisinopril dose is 20 mg (Available) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: What dose of medication do you take for high blood pressure?
  • Finding: Reports taking lisinopril once daily (Available) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: How frequently do you take medication for high blood pressure?
  • Finding: Followed up on high cholesterol medication
  • Finding: Reports taking atorvastatin (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: What medication do you take for high cholesterol?
  • Finding: Reports atorvastatin dose is 20 mg (Available) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: What dose of medication do you take for high cholesterol?
  • Finding: Reports taking atorvastatin once daily (Available) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: How frequently do you take medication for high cholesterol?
  • Finding: Reports taking atorvastatin at bedtime (Available) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: What time of day do you take your high cholesterol medication?
  • Finding: Reports having taken atorvastatin for one year (Available) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: How long have you taken cholesterol medication?

Social Determinants of Health

  • Finding: Asked about access to healthcare
  • Finding: Reports a primary care provider (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Do you have a primary care provider?
  • Finding: Reports last visit 3 months ago (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: When was your last visit to a healthcare provider?
  • Finding: Reports usually sees healthcare provider every 6 months (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: How often do you see a healthcare provider?
  • Finding: Denies transportation is a barrier to healthcare (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Do you have difficulty accessing healthcare because of transportation?
  • Finding: Denies finances are a barrier to healthcare (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Do you have trouble affording healthcare?

Social History

  • Finding: Asked about stress
  • Finding: Reports generally low stress lifestyle (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: What is your stress level?
  • Finding: Asked about exercise
  • Finding: Denies regular exercise routine (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: What kind of exercise do you get?
  • Finding: Reports last regular exercising was 2 years ago (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: When did you last exercise regularly?
  • Finding: Asked about typical diet
  • Finding: Reports typical breakfast is granola bar and instant breakfast shake (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: What is a typical breakfast for you?
  • Finding: Reports typical lunch is turkey sub (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: What is a typical lunch for you?
  • Finding: Reports typical dinner is grilled meat and vegetables (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: What is a typical dinner for you?
  • Finding: Denies moderation of salt intake (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you moderate your salt intake?
  • Finding: Asked about fluid intake
  • Finding: Reports drinking 4 glasses of water daily (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you drink water every day?
  • Finding: Reports drinking 2 cups of coffee daily (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: How much coffee do you drink per day?
  • Finding: Denies soda drinking (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: How much soda do you drink per day?
  • Finding: Asked about substance use
  • Finding: Denies current illicit drug use (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you use illicit drugs?
  • Finding: Denies tobacco use (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you use tobacco?
  • Finding: Reports moderate alcohol consumption (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you consume alcohol?
  • Finding: Followed up on alcohol consumption
  • Finding: Reports drinking 2-3 alcoholic drinks per week (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you drink alcohol?
  • Finding: Reports 2-3 drinks in one sitting (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: How many alcoholic drinks do you have in one sitting?
  • Finding: Reports drinking only on weekends (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: When do you drink alcohol?

Review of Systems

  • Finding: Asked about constitutional health
  • Finding: Denies fever (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have a fever?
  • Finding: Denies chills (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have chills?
  • Finding: Denies fatigue (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you feel tired?
  • Finding: Denies night sweats (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have night sweats?
  • Finding: Denies weight loss (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you experienced recent weight loss?
  • Finding: Denies dizziness or lightheadedness (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have dizziness?
  • Finding: Denies palpitations (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have palpitations?
  • Finding: Asked review of systems for cardiovascular
  • Finding: Denies history of angina (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have a history of angina?
  • Finding: Denies edema (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any swelling?
  • Finding: Denies circulation problems (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any problems with circulation?
  • Finding: Denies blood clots (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you ever had a blood clot?
  • Finding: Denies history of rheumatic fever (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have a history of rheumatic fever?
  • Finding: Denies history of heart murmur (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have a history of heart murmur?
  • Finding: Denies easy bleeding (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you noticed any unusual bleeding?
  • Finding: Denies easy bruising (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you noticed any unusual bruising?
  • Finding: Denies blue skin (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Has your skin ever turned blue?
  • Finding: Asked about review of systems for respiratory
  • Finding: Denies cough (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have a cough?
  • Finding: Denies difficulty breathing (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you had difficulty breathing?
  • Finding: Denies shortness of breath at rest (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have difficulty breathing when lying down?
  • Finding: Asked about review of systems for HEENT
  • Finding: Denies change in sense of taste (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you experienced a change in taste?
  • Finding: Denies sore throat (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have a sore throat?
  • Finding: Denies difficulty swallowing (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have dysphagia?
  • Finding: Asked about review of systems for gastrointestinal
  • Finding: Denies nausea (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have nausea?
  • Finding: Denies vomiting (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you vomited recently?
  • Finding: Denies diarrhea (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have diarrhea?
  • Finding: Denies constipation (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have constipation?
  • Finding: Denies gassiness (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you been gassy?
  • Finding: Denies bloating (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have bloating?
  • Finding: Denies heartburn or GERD (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have heartburn or GERD?

Family Medical History

  • Finding: Asked about relevant family history
  • Finding: Reports family history of heart attack (Available) Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it. Example Question: Has anyone in your family had a heart attack?
  • Finding: Denies family history of stroke (Found) Pro Tip: A patient’s family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient’s current complaint and how their family’s health history might be influencing it. Example Question: Do you have a family history of stroke?
  • Finding: Denies family history of pulmonary embolism

Objective Data Collection: 33 of 33 (100%)

  • 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)

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 abdomen 1 of 1 point

Symmetry (1/3 point)

  • Symmetric
  • Asymmetric

Contour (1/3 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

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 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 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

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 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 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 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

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

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