Felipe Barbosa Sick Visit Integumentary ShadowHealth

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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Objective Data Collection: 10 of 10 (100%)