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Comprehensive Assessment Objective Shadow Health
Health Assessment Of Individuals Across The Lifespan (NUR 3065L)
University of North Florida
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Comprehensive Assessment Results | Turned In
Nursing 562/562L Advanced Health Assessment - Spring 2021, N
Return to Assignment (/assignments/433803/)
Objective Data Collection: 69 of 73 (94%)
HEENT
Your Results Lab Pass (/assignment_attempts/9772464/lab_pass
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Documentation
Plan My Exam
Program Competency Progress
Indicates an item that you found. Indicates an item that is available to be found.
Category Scored Items
Experts selected these examinations as essential components of objective data collection for this patient.
Patient Data
Not Scored
Thorough examinations will yield better patient data The following actions reveal the objective data of th patient's case.
Inspected head and neck Scattered pustules on face and facial hair on upper lip Head is normocephalic, atraumatic Normal scalp hair distribution Acanthosis nigricans noted on neck
Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema
Palpated scalp No masses
Palpated sinuses No frontal sinus tenderness No maxillary sinus tenderness
Palpated jaw No clicks, full ROM
Palpated lymph nodes No axillary lymphadenopathy No supraclavicular lymphadenopathy
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Respiratory
Palpated thyroid Thyroid smooth without nodules, no goiter
Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, white sclera Lower eyelids: conjunctiva pink, no lesions, white sclera
Tested PERRL with penlight Right pupil: equal, round, reactive to light Left pupil: equal, round, reactive to light
Tested eye movements Normal convergence EOMs intact bilaterally, no nystagmus
Tested peripheral vision Peripheral vision intact in both eyes, all fields
Inspected interior eyes with ophthalmoscope Mild retinopathic changes on right Left fundus with sharp disc margins, no hemorrhages
Tested visual acuity Vision 20/20 right eye with corrective lenses Vision 20/20 left eye with corrective lenses
Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline on right Nasal mucosa moist and pink, septum midline on left
Examined ear cavities with otoscope Right TM intact and pearly gray, positive light reflex Left TM intact and pearly gray, positive light reflex
Practiced whisper test Whispered words heard on right Whispered words heard on left
Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or lesions, uvula midline Gag reflex intact
Tested pulse oximetry Oxygen saturation 99%
Tested lung capacity FVC is 3 L and FEV1/FVC ratio is 80%
Inspected chest wall Anterior chest wall symmetric, no deformity or lesions Posterior chest wall symmetric, no deformity or lesions
Palpated thoracic expansion Thoracic expansion symmetric
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Gastrointestinal
Palpated pulses of the upper extremities Right radial pulse: 2+ Right brachial pulse: 2+ Left brachial pulse: 2+ Left radial pulse: 2+
Palpated pulses of the lower extremities Right femoral pulse: 2+ Right popliteal pulse: 2+ Right tibial pulse: 2+ Right dorsalis pedis pulse: 2+ Left femoral pulse: 2+ Left popliteal pulse: 2+ Left tibial pulse: 2+ Left dorsalis pedis pulse: 2+
Auscultated arteries in the head and neck Right carotid artery: no bruit Left carotid artery: no bruit
Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S Auscultated Erb's point with the diaphragm: RRR, S1, S2, no murmur Auscultated aortic area with the bell: no S3, S Auscultated aortic area with the diaphragm: RRR, S1, S2, no murmur Auscultated pulmonic area with the bell: no S3, S Auscultated pulmonic area with the diaphragm: RRR, S1, S2, no murmur Auscultated tricuspid area with the bell: no S3, S Auscultated tricuspid area with the diaphragm: RRR, S1, S2, no murmur Auscultated mitral area with the bell: no S3, S Auscultated mitral area with the diaphragm: RRR, S1, S2, no murmur
Auscultated arteries of the body Right renal artery: no bruit Right iliac artery: no bruit Right femoral artery: no bruit Left renal artery: no bruit Left iliac artery: no bruit Left femoral artery: no bruit
Performed Capillary Refill Capillary Refill < 3 sec
Inspected for edema Left leg: no edema Right leg: no edema
Inspected abdomen Abdomen protuberant, symmetric, no visible masses or lesions, coarse hair from pubis to umbilicus
Auscultated bowel sounds Right upper quadrant: normoactive
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Musculoskeletal
Left upper quadrant: normoactive Left lower quadrant: normoactive
Auscultated arterial sounds Aortic artery: no bruit
Percussed CVA tenderness Right flank: none reported Left flank: none reported
Percussed organs Spleen percussion: no dullness Liver span: 7 cm MCL on percussion
Percussed abdomen Right upper quadrant: tympanic Right lower quadrant: tympanic Left lower quadrant: tympanic Left upper quadrant: tympanic
Palpated abdomen - light Right upper quadrant: soft, no tenderness or masses Right lower quadrant: soft, no tenderness or masses Left lower quadrant: soft, no tenderness or masses Left upper quadrant: soft, no tenderness or masses
Palpated abdomen - deep Right upper quadrant: no masses, guarding or rebound Right lower quadrant: no masses, guarding or rebound Left upper quadrant: no masses, guarding or rebound Left lower quadrant: no masses, guarding or rebound
Palpated organs Liver: palpable 1 cm below right costal margin Spleen: not palpable Right kidney: not palpable, no masses Left kidney: not palpable, no masses
Inspected neck Neck without swelling, masses, or deformity
Inspected upper extremities Right shoulder without swelling, masses, or deformity Right arm without swelling, masses, or deformity Right elbow without swelling, masses, or deformity Right wrist and hand without swelling, masses, or deformity Left shoulder without swelling, masses, or deformity Left arm without swelling, masses, or deformity Left elbow without swelling, masses, or deformity Left wrist and hand without swelling, masses, or
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Tested ability to sense light touch of upper extremities
Right arm proximal light touch sensation intact Right arm distal light touch sensation intact Left arm proximal light touch sensation intact Left arm distal light touch sensation intact
Tested ability to sense light touch of lower extremities
Right leg proximal light touch sensation intact Right leg distal light touch sensation intact Left leg proximal light touch sensation intact Left leg distal light touch sensation intact
Tested ability to sense dull pain in upper extremities
Right arm proximal dull pain sensation intact Right arm distal dull pain sensation intact Left arm proximal dull pain sensation intact Left arm distal dull pain sensation intact
Tested ability to sense dull pain in lower extremities
Right leg proximal dull pain sensation intact Right leg distal dull pain sensation intact Left leg proximal dull pain sensation intact Left leg distal dull pain sensation intact
Tested ability to sense sharp pain in upper extremities
Right arm proximal sharp pain sensation intact Right arm distal sharp pain sensation intact Left arm proximal sharp pain sensation intact Left arm distal sharp pain sensation intact
Tested ability to sense sharp pain in lower extremities
Right leg proximal sharp pain sensation intact Right leg distal sharp pain sensation intact Left leg proximal sharp pain sensation intact Left leg distal sharp pain sensation intact
Tested position sense Position sense intact in toes Position sense intact in fingers
Tested stereognosis Identified coin in right hand within 5 seconds Identified paperclip in right hand within 5 seconds Identified key in right hand within 5 seconds Identified coin in left hand within 5 seconds Identified paperclip in left hand within 5 seconds Identified key in left hand within 5 seconds
Tested deep tendon reflexes of upper extremities
Right triceps: 2+ Right biceps: 2+ Right brachioradialis: 2+ Left triceps: 2+ Left biceps: 2+ Left brachioradialis: 2+
Tested deep tendon reflexes of lower extremities
Right ankle: 2+ Right knee: 2+ Left knee: 2+ Left ankle: 2+
Tested finger-to-nose coordination Right finger to nose: smooth and accurate
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Tested heel-to shin-coordination Right foot straight line down shin, smooth and accurate Left foot straight line down shin, smooth and accurate
Tested rapid alternating hand movements Rapid alternating hand movements: smooth
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Comprehensive Assessment Objective Shadow Health
Course: Health Assessment Of Individuals Across The Lifespan (NUR 3065L)
University: University of North Florida
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