Shoshanna Tillman Shadow Health
Objective Data Collection: 20 of 21 (95.24%)
Correct
Partially correct
Incorrect
Missed
Auscultated Heart Sounds
0.5 of 1 point
Heart Sounds (No point)
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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
Auscultated Breath Sounds
1 of 1 point
Breath Sounds (1/3 point)
Clear 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
Shoshanna Tillman Follow Up Sick Visit: Musculoskeletal Shadow Health Transcript
Location (1/3 point)
All areas clear
Adventitious sounds in anterior right upper lobe
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
Shoshanna Tillman Shadow Health Objective Data
Inspected Eyes
1 of 1 point
Orbital Area (1/4 point)
No visible abnormal findings
Ptosis
Eyelid edema
Lesion
Sclera (1/4 point)
White
Yellow tint
Redness
Conjunctiva (1/4 point)
Moist and pink
Dry appearance
Redness
Swelling
Conjunctival Discharge (1/4 point)
No discharge
Clear, watery discharge
Purulent discharge
Inspected Mouth
1 of 1 point
Oral Mucosa (1/1 point)
Moist and pink
Dry appearance
Redness
Inspected Skin, Hair, and Nails
1 of 1 point
Skin (1/3 point)
No visible abnormal findings
Edema
Redness
Rash
Moles
Masses (warts, cysts, or tumors)
Freckles, birthmarks, or other discoloration
Excessive dry or flaking skin
Purpura
Scarring
Laceration, lesion, or wound
Bruising
Hair (1/3 point)
No visible abnormal findings
Balding or hair thinning
Dandruff
Scalp discoloration
Nails (1/3 point)
No visible abnormal findings
Pallor
Cyanosis
Reperfusion
Splinter hemorrhages
Grooves
Fungus
Peeling
Clubbing
Inspected Hands and Wrists
1 of 1 point
Hands (1/2 point)
No visible abnormal findings
Redness
Moles or skin tags
Masses (warts, cysts, or tumors)
Freckles, birthmarks, or other discoloration
Excessive dry or flaking skin
Purpura
Scarring
Laceration, lesion, or wound
Bruising
Rash
Wrists (1/2 point)
No visible abnormal findings
Swelling
Visible mass
Irregular alignment
Discoloration
Atrophy
Hypertrophy
Joint deformity
Inspected Lower Extremities
1 of 1 point
Appearance (1/1 point)
No visible abnormal findings
Discoloration
Edema
Skin thickening
Ulceration
Varicose veins
Visible distortion or swelling
Palpated Thyroid
1 of 1 point
Observations (1/2 point)
No palpable abnormal findings
Nodules
Enlarged
Irregular
Tenderness (
1/2 point)
None reported
Tenderness reported
Palpated Upper Extremities
1 of 1 point
Right Forearm (1/4 point)
No abnormal findings
Pitting edema
Tenderness
Warmth
Left Forearm (1/4 point)
No abnormal findings
Pitting edema
Tenderness
Warmth
Right Upper Arm (1/4 point)
No abnormal findings
Pitting edema
Tenderness
Warmth
Walden’s NURS 6053: Interprofessional Organization and System Leadership
Left Upper Arm (1/4 point)
No abnormal findings
Pitting edema
Tenderness
Warmth
Palpated Lower Extremities
1 of 1 point
Right Calf (1/6 point)
No abnormal findings
Pitting edema
Tenderness
Warmth
Left Calf (1/6 point)
No abnormal findings
Pitting edema
Tenderness
Warmth
Right Ankle (1/6 point)
No abnormal findings
Pitting edema
Tenderness
Warmth
Left Ankle (1/6 point)
No abnormal findings
Pitting edema
Tenderness
Warmth
Right Foot (1/6 point)
No abnormal findings
Pitting edema
Tenderness
Warmth
Left Foot (1/6 point)
No abnormal findings
Pitting edema
Tenderness
Warmth
Palpated Finger and Wrist Joints
0.5 of 1 point
Right Hand Observations (1/4 point)
No palpable abnormal findings
Palpable abnormal findings
Right Hand Tenderness (No point)
None reported
Tenderness reported
Left Hand Observations (1/4 point)
No palpable abnormal findings
Palpable abnormal findings
Left Hand Tenderness (No point)
None reported
Tenderness reported
Palpated Radial Pulses
1 of 1 point
Right Radial Pulse (1/2 point)
2+ Normal
1+ Diminished
0 Absent
Left Radial Pulse (1/2 point)
2+ Normal
1+ Diminished
0 Absent
Finklestein’s Test
1 of 1 point
Right Hand (1/2 point)
Positive
Negative
Left Hand (1/2 point)
Positive
Negative
Tinel’s Test
1 of 1 point
Right Hand (1/2 point)
Positive
Negative
Left Hand (1/2 point)
Positive
Negative
Phalen’s Test
1 of 1 point
Right Hand (1/2 point)
Positive
Negative
Left Hand (1/2 point)
Positive
Negative
OK Sign Test
1 of 1 point
Right Hand (1/2 point)
Positive
Negative
Left Hand (1/2 point)
Positive
Negative
Tested Wrist and Fingers ROM
1 of 1 point
Left Wrist (1/4 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Right Wrist (1/4 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Left Hand Fingers (1/4 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Right Hand Fingers (1/4 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Tested Squeezing Strength
1 of 1 point
Left Hand Fingers (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Right Hand Fingers (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Tested Pushing Strength
1 of 1 point
Left Hand Fingers (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Right Hand Fingers (1/2 point)
0 – No muscle contraction
1 – Barely detectable contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)
Tested Sensation in Hands
1 of 1 point
Right (1/2 point)
Expected sensation
Decreased sensation
Left (1/2 point)
Expected sensation
Decreased 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
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Shoshanna Tillman Shadow Health
Objective Data Collection: 20 of 21 (95.24%)
- Correct
- Partially correct
- Incorrect
- Missed
- 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
- Clear in all areas
- Diminished in some areas
- Absent in some areas
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
- All areas clear
- Adventitious sounds in anterior right upper lobe
- 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
- Shoshanna Tillman Shadow Health Objective Data
- No visible abnormal findings
- Ptosis
- Eyelid edema
- Lesion
- White
- Yellow tint
- Redness
- Moist and pink
- Dry appearance
- Redness
- Swelling
- No discharge
- Clear, watery discharge
- Purulent discharge
- Moist and pink
- Dry appearance
- Redness
- No visible abnormal findings
- Edema
- Redness
- Rash
- Moles
- Masses (warts, cysts, or tumors)
- Freckles, birthmarks, or other discoloration
- Excessive dry or flaking skin
- Purpura
- Scarring
- Laceration, lesion, or wound
- Bruising
- No visible abnormal findings
- Balding or hair thinning
- Dandruff
- Scalp discoloration
- No visible abnormal findings
- Pallor
- Cyanosis
- Reperfusion
- Splinter hemorrhages
- Grooves
- Fungus
- Peeling
- Clubbing
- No visible abnormal findings
- Redness
- Moles or skin tags
- Masses (warts, cysts, or tumors)
- Freckles, birthmarks, or other discoloration
- Excessive dry or flaking skin
- Purpura
- Scarring
- Laceration, lesion, or wound
- Bruising
- Rash
- No visible abnormal findings
- Swelling
- Visible mass
- Irregular alignment
- Discoloration
- Atrophy
- Hypertrophy
- Joint deformity
- No visible abnormal findings
- Discoloration
- Edema
- Skin thickening
- Ulceration
- Varicose veins
- Visible distortion or swelling
- No palpable abnormal findings
- Nodules
- Enlarged
- Irregular
- None reported
- Tenderness reported
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
- No palpable abnormal findings
- Palpable abnormal findings
- None reported
- Tenderness reported
- No palpable abnormal findings
- Palpable abnormal findings
- None reported
- Tenderness reported
- 2+ Normal
- 1+ Diminished
- 0 Absent
- 2+ Normal
- 1+ Diminished
- 0 Absent
- Positive
- Negative
- Positive
- Negative
- Positive
- Negative
- Postive
- Negative
- Positive
- Negative
- Positive
- Negative
- Positive
- Negative
- Positive
- Negative
- 0 – No muscle contraction
- 1 – Barely detectable contraction
- 2 – Active movement with gravity eliminated
- 3 – Active movement against gravity
- 4 – Active movement against gravity and resistance
- 5 – Active movement against full resistance without fatigue (normal)
- 0 – No muscle contraction
- 1 – Barely detectable contraction
- 2 – Active movement with gravity eliminated
- 3 – Active movement against gravity
- 4 – Active movement against gravity and resistance
- 5 – Active movement against full resistance without fatigue (normal)
- 0 – No muscle contraction
- 1 – Barely detectable contraction
- 2 – Active movement with gravity eliminated
- 3 – Active movement against gravity
- 4 – Active movement against gravity and resistance
- 5 – Active movement against full resistance without fatigue (normal)
- Shoshanna Tillman Shadow Health Objective Data
- 0 – No muscle contraction
- 1 – Barely detectable contraction
- 2 – Active movement with gravity eliminated
- 3 – Active movement against gravity
- 4 – Active movement against gravity and resistance
- 5 – Active movement against full resistance without fatigue (normal)
- 0 – No muscle contraction
- 1 – Barely detectable contraction
- 2 – Active movement with gravity eliminated
- 3 – Active movement against gravity
- 4 – Active movement against gravity and resistance
- 5 – Active movement against full resistance without fatigue (normal)
- 0 – No muscle contraction
- 1 – Barely detectable contraction
- 2 – Active movement with gravity eliminated
- 3 – Active movement against gravity
- 4 – Active movement against gravity and resistance
- 5 – Active movement against full resistance without fatigue (normal)
- 0 – No muscle contraction
- 1 – Barely detectable contraction
- 2 – Active movement with gravity eliminated
- 3 – Active movement against gravity
- 4 – Active movement against gravity and resistance
- 5 – Active movement against full resistance without fatigue (normal)
- Shoshanna Tillman Shadow Health Objective Data
- 0 – No muscle contraction
- 1 – Barely detectable contraction
- 2 – Active movement with gravity eliminated
- 3 – Active movement against gravity
- 4 – Active movement against gravity and resistance
- 5 – Active movement against full resistance without fatigue (normal)
- Expected sensation
- Decreased sensation
- Expected sensation
- Decreased sensation
- Expected sensation
- Decreased sensation
- Expected sensation
- Decreased sensation
- Shoshanna Tillman Shadow Health Objective Data