Objective Data Collection: 27.67 of 28 (98.82%)

Correct
Partially correct
Incorrect
Missed

Assessed Vitals
1 of 1 point

Temperature (1/5 point)
Normothermic
Hyperthermic
Hypothermic

Blood Pressure (1/5 point)
Normotensive
Hypertensive
Hypotensive

Heart Rate (1/5 point)
Normal
Tachycardic
Bradycardic

Respiratory Rate (1/5 point)
Normal
Tachypnea
Bradypnea

O2 Saturation (1/5 point)
Normal
Hypoxemia

Inspected Legs
1 of 1 point

Right: Appearance (1/3 point)
No visible abnormal findings
Redness
Bruising or other discoloration
Edema
Visible mass
Atrophy
Hypertrophy

Left: Appearance (1/3 point)
No visible abnormal findings
Redness
Bruising or other discoloration
Edema
Visible mass
Atrophy
Hypertrophy

Symmetry (1/3 point)
Symmetric bilaterally
Asymmetric

Felipe Barbosa Sick Visit Integumentary ShadowHealth

Inspected Nose
1 of 1 point

Color (1/3 point)
Pink
Red
Bluish

Discharge (1/3 point)
No discharge
Clear discharge
Bloody discharge
Purulent discharge

Observations (1/3 point)
No additional visible abnormal findings
Foreign body present
Polyp
Septum perforated
Septum deviated
Lesion

Inspected Back
1 of 1 point

Appearance (1/1 point)
No visible abnormal findings
Rash
Moles or skin tags
Freckles, birthmark, or other discoloration
Excessive dry or flaking skin
Purpura
Striae
Scratching
Bruising

Inspected Eyes
1 of 1 point

Pupillary Reaction (1/3 point)
Normal
Unequal
Irregular
Miosis
Mydriasis
Non-reactive to light

Reaction (1/3 point)
Normal constriction and dilation
Unequal or no pupillary constriction
Unequal or no pupillary dilation

Sclera (1/3 point)
White
Yellow Tint
Redness

Inspected Chest
1 of 1 point

Symmetry (1/2 point)
Symmetric
Asymmetric

Appearance (1/2 point)
No visible abnormal findings
Redness
Rash
Moles or skin tags
Masses (warts, cysts, or tumors)
Freckles, birthmark, or other discoloration
Excessive dry or flaking skin
Purpura
Striae
Bruising
Scarring

Inspected Arms
0.67 of 1 point

Observations (1/3 point)
No visible evidence of self-harm or abuse
Evidence of self-harm

Wounds Or Scars (1/3 point)
No visible wounds or scars
Wound visible
Scar visible

Location Of Visible Abnormality (No point)
No visible abnormality
Right upper arm
Right lower arm
Right wrist
Right hand
Left upper arm
Left lower arm
Left wrist
Left hand

Auscultated Breath Sounds
1 of 1 point

Breath Sounds (1/2 point)
Clear in all areas
Diminished in some areas
Absent in some areas

Adventitious Sounds (1/2 point)
No adventitious sounds
Wheezing
Fine crackles
Stridor
Rhonchi
Rales

Auscultated Heart Sounds
1 of 1 point

Heart Sounds (1/3 point)
S1 and S2 audible
S1, S2, and S3 audible
S1, S2, and S4 audible
S1, S2, S3, and S4 audible

Extra Heart Sounds (1/3 point)
No extra sounds
Gallops
Murmur
Friction rub
Valve clicks

Rate And Rhythm (1/3 point)
Regular rate and rhythm
Irregular rate
Arrhythmia

Palpated Capillary Refill
1 of 1 point

Right Hand (1/2 point)
Less than 2 seconds
Greater than 2 seconds

Left Hand (1/2 point)
Less than 2 seconds
Greater than 2 seconds

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
Thrills

Left: Amplitude (1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse

Shoshanna Tillman Follow Up Sick Visit: Musculoskeletal Shadow Health Transcript

Palpated Dorsalis Pedis Arteries
1 of 1 point

Right: Vibration (1/4 point)
No Thrill
Thrills

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
Thrills

Left: Amplitude (1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse

Palpated Abdomen
1 of 1 point

Tenderness (1/5 point)
None Reported
Tenderness Reported

Location Of Tenderness (1/5 point)
No quadrants tender
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant

Observations (1/5 point)
No additional observations
Masses
Guarding
Distension

Presence Of Unexpected Mass (1/5 point)
No palpable mass
Palpable mass

Location Of Mass (1/5 point)
No palpable mass
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Around umbilicus

Performed EKG
1 of 1 point

Sinus Rhythm (1/2 point)
Regular
Irregular

St Changes (1/2 point)
No ST elevation
ST elevation present

Assessed Labs

1 of 1 point

Drug Screen Results (1/2 point)
Positive for substances
Negative for substances

Thyroid Function Tests (1/2 point)
Both levels within normal ranges
Thyroxine-binding globulin elevated
Thyroxine-binding globulin low
Thyroid-stimulating hormone (TSH) elevated
Thyroid-stimulating hormone (TSH) low

Assessed General Appearance
1 of 1 point

Eye Contact (1/4 point)
Direct eye contact
Indirect or no eye contact

Posture (1/4 point)
Upright posture without tension or rigidity
Bent or hunched posture, tension, or rigidity

Clothing (1/4 point)
Clean clothing, appropriate to age, fit, season, and occasion
Dirty, disheveled, or inappropriate to age, fit, season, or occasion

Grooming (1/4 point)
Demonstrates an appropriate level of grooming
Signs indicating lack of grooming or self-care

Assessed Attitude Toward Medical Staff
1 of 1 point

Attitude Toward Medical Staff (1/1 point)
Generally open and cooperative
Generally suspicious, guarded, or evasive

Assessed Speech
1 of 1 point

Rate (1/3 point)
Demonstrates appropriate or expected rate of speech
Excessively slow or rapid rate of speech

Volume (1/3 point)
Demonstrates appropriate or expected speech volume
Excessively loud or soft speech volume

Articulation (1/3 point)
No appreciable issues with articulation
Issues with articulation, slurring, or stutters

Assessed Mood and Affect
1 of 1 point

Mood (1/2 point)
Stable mood with little or no fluctuation throughout the interview
Frequent and appreciable mood changes throughout the interview

Affect (1/2 point)
Full or balanced (normal)
Expansive affect (excessively cheerful affect characterized by contagious laughter or smiling)
Blunted or flat affect (little to no variation of expression regardless of conversation topic)

Assessed Thought Process
1 of 1 point

Thought Process (1/1 point)
No presence of thought process disturbances
Presence of rapid thinking, disorganized or illogical flow of thought, “word salad,” neologisms, echolalia, or clanging associations

Assessed Thought Content
1 of 1 point

Thought Content (1/2 point)
No presence of thought content disturbances
Presence of delusions, obsessive or intrusive thoughts, or suicidal or homicidal ideation

Perceptual Disturbances (1/2 point)
No presence of perceptual disturbances
Presence of auditory or visual hallucinations

Confirmed Orientation
1 of 1 point

To Person (1/4 point)
Oriented to person
Not oriented to person

To Place (1/4 point)
Oriented to place
Not oriented to place

To Time (1/4 point)
Oriented to time
Not oriented to time

To Situation (1/4 point)
Oriented to situation
Not oriented to situation

Assessed Serial Sevens
1 of 1 point

Serial Sevens (1/1 point)
Able to complete the series
Unable to complete the series

Assessed Abstract Thinking
1 of 1 point

Abstract Thinking (1/1 point)
Demonstrates abstract thinking with similarities test
Demonstrates concrete thinking with similarities test

Assessed Memory
1 of 1 point

Memory (1/1 point)
Remote and immediate memory intact
Remote or immediate memory not intact

Assessed Visuospatial Ability
1 of 1 point

Visuospatial Ability (1/1 point)
Visuospatial ability intact for interlocking shapes test
Visuospatial ability impaired with interlocking shapes test

Assessed Insight
1 of 1 point

Insight (1/1 point)
Demonstrates full awareness of illness and willingness to seek treatment
Demonstrates limited or no awareness of illness and/or is unwilling to seek treatment

Liam Fitzgerald Telehealth Follow Up Sick Visit Shadow Health Transcript

Assessed Judgment
1 of 1 point

Judgment (1/1 point)
Demonstrates good judgment
Judgment poor or impaired judgment

Lucas Callahan Bipolar Disorder

Objective Data Collection: 27.67 of 28 (98.82%)