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Shoshanna Tillman Shadow Health

Shoshanna Tillman Shadow Health

Objective Data Collection: 20 of 21 (95.24%)

Shoshanna Tillman.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
 Auscultated Heart Sounds
0.5 of 1 point
Heart Sounds (No 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
 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
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
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)
  •  Postive
  •  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)
  • Shoshanna Tillman Shadow Health Objective Data
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)
  • Shoshanna Tillman Shadow Health Objective Data
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
  • Shoshanna Tillman Shadow Health Objective Data

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