Maya Parker Ear Pain Shadow Health

Objective Data Collection: 13.5 of 14 (96.0%)

Assess Pain
– Pain: 1 out of 1 point
– 0 – “No Hurt”
– 2 – “Hurts Little Bit”
– 4 – “Hurts Little More”
– 6 – “Hurts Even More”
– 8 – “Hurts Whole Lot”
– 10 – “Hurts Worse”

Inspect Head
– Appearance: 1 out of 1 point
– Symmetric
– Asymmetric

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Inspect Face
– Appearance: 1 out of 1 point
– Symmetric
– Asymmetric

Inspect Neck
– Appearance: 1 out of 1 point
– No visible abnormal findings
– Swelling
– Visible pulsation
– Visible mass

Examine Mouth
– Oral Mucosa Appearance: 0.75 out of 1 point
– Moist
– Dry
– Oral Mucosa Color: Pink, Erythema
– Posterior Oropharynx: Erythemic, Cobblestone appearance, Exudate, Pink
– Tonsils: 0 (Tonsils fit within tonsillar fossa) to 4+ (Tonsils >75% of space between pillars)

Auscultate Abdomen
– Bowel Sounds: Absent, Hypoactive, Normoactive, Hyperactive

Auscultate Heart
– Heart Sounds: S1 and S2 audible, S1, S2 and S3 audible, S1, S2, and S4 audible
– Extra Heart Sounds: No extra heart sounds, Gallups, Murmur, Friction rubs
– Rate: Regular rate, Irregular rate
– Rhythm: Regular Rhythm, Irregular Rhythm

Auscultate Lungs
– Appearance: Accessory muscle use, No distress
– Symmetry: Symmetrical chest rise and fall, Asymmetrical chest rise and fall
– Breath Sounds: Clear in all areas, Diminished in some areas, Absent in some areas
– Adventitious Sounds: No adventitious sounds, Wheezing, Crackles, Stridor, Rhonchi

Hearing Test
– Hearing: Responds to questions, Requests excessive repetition, Erratic voice volume
– Whisper Test: Repeats words correctly >50% of the time, Unable to repeat whispered sounds

Inspect Auricles
– Left Auricle: No visible abnormalities, Bruising, Deformity, Erythema
– Right Auricle: No visible abnormalities, Bruising, Deformity, Erythema

Palpate Auricles
– Right Ear Palpation: Non-tender, Tender
– Left Ear Palpation: Non-tender, Tender

Inspect Nose
– Color: Bluish, Red, Pink
– Discharge: Bloody discharge, Clear discharge, No discharge, Purulent discharge
– Turbinate Patency: Decreased patency, Not patent, Patent
– Observations: No additional visible abnormal findings, Foreign body present, Lesion, Polyp, Septum deviated, Septum perforated

Inspect Inner Ears
– Left: Auditory Canal Color: Erythema, No visible abnormal findings, Pallor
– Left: Tympanic Membrane Color: Not visible because of cerumen, Opaque, Pearly gray, Red, Yellow
– Left: Tympanic Membrane Appearance: No visible abnormal findings, Bulging, Fluid observed, Perforation, Retraction, Visible scars
– Left: Cone Of Light: 7:00, Cone of light distorted
– Left: Discharge: Bloody discharge, Clear discharge, No discharge, Purulent discharge, Cerumen

– Right: Auditory Canal Color: Erythema, No visible abnormal findings, Pallor
– Right: Tympanic Membrane Color: Not visible because of cerumen, Opaque, Pearly gray, Red, Yellow
– Right: Tympanic Membrane Appearance: No visible abnormal findings, Bulging, Fluid observed, Perforation, Retraction, Visible scars
– Right: Cone Of Light: 5:00, Cone of light distorted
– Right: Discharge: Bloody discharge, Clear discharge, No discharge, Purulent discharge, Cerumen

Inspect Mobility of Tympanic Membranes
– Left: Immobile, Mobile
– Right: Immobile, Mobile

Maya Parker Ear Pain Shadow Health

Objective Data Collection: 13.5 of 14 (96.0%)

 Assess Pain

1 of 1 point

Pain (1/1 point)

•  0 – “No Hurt”
•  2 – “Hurts Little Bit”
•  4 – “Hurts Little More”
•  6 – “Hurts Even More”
•  8 – “Hurts Whole Lot”
•  10 – “Hurts Worse”

 Inspect Head

1 of 1 point

Appearance (1/1 point)

•  Symmetric
•  Asymmetric
• Maya Parker Ear Pain Shadow Health Objective Data

 Inspect Face

1 of 1 point

Appearance (1/1 point)

•  Symmetric
•  Asymmetric

 Inspect Neck

1 of 1 point

Appearance (1/1 point)

•  No visible abnormal findings
•  Swelling
•  Visible pulsation
•  Visible mass

 Examine Mouth

0.75 of 1 point

Oral Mucosa Appearance (1/4 point)

•  Moist
•  Dry

Oral Mucosa Color (1/4 point)

•  Pink
•  Erythema

Posterior Oropharynx (1/4 point)

•  Erythemic
•  Cobblestone appearance
•  Exudate
•  Pink

Conditions of the Hematologic System Anita Douglas Shadow Health

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Tonsils (No point)

•  0: Tonsils fit within tonsillar fossa
•  1+: Tonsils <25% of space between pillars
•  2+: Tonsils <50% of space between pillars
•  3+: Tonsils <75% of space between pillars
•  4+ Tonsils >75% of space between pillars

 Auscultate Abdomen

1 of 1 point

Bowel Sounds (1/1 point)

•  Absent
•  Hypoactive
•  Normoactive
•  Hyperactive

 Auscultate Heart

1 of 1 point

Heart Sounds (1/4 point)

•  S1 and S2 audible
•  S1, S2 and S3 audible
•  S1, S2, and S4 audible
•  S1, S2, S3, and S4 audible

Extra Heart Sounds (1/4 point)

•  No extra heart sounds
•  Gallups
•  Murmur
•  Friction rubs

Rate (1/4 point)

•  Regular rate
•  Irregular rate

Rhythm (1/4 point)

•  Regular Rhythm
•  Irregular Rhythm

 Auscultate Lungs

1 of 1 point

Appearance (1/4 point)

•  Accessory muscle use
•  No distress

Symmetry (1/4 point)

•  Symmetrical chest rise and fall
•  Asymmetrical chest rise and fall

Breath Sounds (1/4 point)

•  Clear in all areas
•  Diminished in some areas
•  Absent in some areas

Adventitious Sounds (1/4 point)

•  No adventitious sounds
•  Wheezing
•  Crackles
•  Stridor
•  Rhonchi

 Hearing Test

1 of 1 point

Hearing (1/2 point)

•  Responds to questions
•  Requests excessive repetition
•  Erratic voice volume

Whisper Test (1/2 point)

•  Repeats words correctly >50% of the time
•  Unable to repeat whispered sounds
• Maya Parker Ear Pain Shadow Health Objective Data

 Inspect Auricles

1 of 1 point

Left Auricle (1/2 point)

•  No visible abnormalities
•  Bruising
•  Deformity
•  Erythema

Right Auricle (1/2 point)

•  No visible abnormalities
•  Bruising
•  Deformity
•  Erythema

 Palpate Auricles

1 of 1 point

Right Ear Palpation (1/2 point)

•  Non-tender
•  Tender

Maya Parker Ear Pain Shadow Health Objective Data Left Ear Palpation (1/2 point)

•  Non-tender
•  Tender

 Inspect Nose

1 of 1 point

Color (1/4 point)

•  Bluish
•  Red
•  Pink

Discharge (1/4 point)

•  Bloody discharge
•  Clear discharge
•  No discharge
•  Purulent discharge

Turbinate Patency (1/4 point)

•  Decreased patency
•  Not patent
•  Patent

Observations (1/4 point)

•  No Additional visible abnormal findings
•  Foreign body present
•  Lesion
•  Polyp
•  Septum deviated
•  Septum perforated

 Inspect Inner Ears

0.5 of 1 point

Left: Auditory Canal Color (1/10 point)

•  Erythema
•  No visible abnormal findings
•  Pallor

Left: Tympanic Membrane Color (1/10 point)

•  Not visible because of cerumen
•  Opaque
•  Pearly gray
•  Red
•  Yellow

Left: Tympanic Membrane Appearance (1/10 point)

•  No visible abnormal findings
•  Bulging
•  Fluid observed
•  Perforation
•  Retraction
•  Visible scars
• Maya Parker Ear Pain Shadow Health Objective Data
• Maya Parker Ear Pain Shadow Health Objective Data

Left: Cone Of Light (1/10 point)

•  7:00
•  Cone of light distorted

Left: Discharge (1/10 point)

•  Bloody discharge
•  Clear discharge
•  No discharge
•  Purulent discharge
•  Cerumen

Right: Auditory Canal Color (No point)

•  Erythema
•  No visible abnormal findings
•  Pallor

Right: Tympanic Membrane Color (No point)

•  Not visible because of cerumen
•  Opaque
•  Pearly gray
•  Red
•  Yellow

Right: Tympanic Membrane Appearance (No point)

•  No visible abnormal findings
•  Bulging
•  Fluid observed
•  Perforation
•  Retraction
•  Visible scars

Right: Cone Of Light (No point)

•  5:00
•  Cone of light distorted

Right: Discharge (No point)

•  Bloody discharge
•  Clear discharge
•  No discharge
•  Purulent discharge
•  Cerumen

 Inspect Mobility of Tympanic Membranes

1 of 1 point

Left (1/2 point)

•  Immobile
•  Mobile

Right (1/2 point)

•  Immobile
•  Mobile
• Maya Parker Ear Pain Shadow Health Objective Data