Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data

Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data

Objective Data Collection: 10 Of 10 (100%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed
 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
  • Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data
  •  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 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
 Assessed Location of Rash
1 of 1 point
Plane (1/2 point)
  •  Left side of torso
  •  Right side of torso
  •  Left side of back
  •  Right side of back
  •  Left side of body
  •  Right side of body
Dermatome (1/2 point)
  •  Cervical
  •  Thoracic
  •  Lumbar
  •  Sacral
  •  Coccygeal
 Assessed Character of Rash
1 of 1 point
Character Of Rash (1/1 point)
  •  Clustered
  •  Satellite
  •  Non-vesicular
  •  Vesicular
  •  Dermatomal
  •  Herald patch
  •  Bilateral
  •  Unilateral
 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
  •  Distention
 Palpated Spine
1 of 1 point
Palpated Spine (1/2 point)
  •  Spinous process nontender to palpation
  •  Spinous process tender to palpation
  • Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data
Palpated Spine Accessory Muscles (1/2 point)
  •  Accessory muscles nontender to palpation
  •  Accessory muscles tender to palpation
 Palpated Rash
1 of 1 point
Palpated Rash (1/1 point)
  •  Tenderness with palpation
  •  Non-tender with palpation
 Tested Sensation in Legs
1 of 1 point
Right Touch (1/2 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Left Touch (1/2 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
 Tested Sensation in Feet
1 of 1 point
Right (1/2 point)
  •  Expected sensation
  •  Decreased sensation
Left (1/2 point)
  •  Expected sensation
  •  Decreased sensation
 Tested Spine ROM
1 of 1 point
Extension (1/4 point)
  •  Expected range of motion (approx. 30 degrees)
  •  Reduced extension
Flexion (1/4 point)
  •  Expected range of motion (approx. 75-90 degrees)
  •  Reduced flexion
Lateral Bending (1/4 point)
  •  Expected range of motion bilaterally (approx. 35 degrees)
  •  Reduced lateral bending to the right
  •  Reduced lateral bending to the left
Rotation (1/4 point)
  •  Expected range of motion bilaterally (approx. 30 degrees)
  •  Reduced rotation to the right
  •  Reduced rotation to the left

 

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