Integumentary Felipe Barbosa Sick Visit Shadow Health Objective Data Collection

•  Present in all areas
•  Diminished in some areas
•  Absent in some areas

Noah Caputo school age sick visit dermatology shadow health Subjective data Collection

•  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

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

•  No extra sounds
•  Gallops
•  Murmur
•  Friction rub
•  Valve clicks

•  Left side of torso
•  Right side of torso
•  Left side of back
•  Right side of back
•  Left side of body
•  Right side of body

•  Cervical
•  Thoracic
•  Lumbar
•  Sacral
•  Coccygeal

•  Clustered
•  Satellite
•  Non-vesicular
•  Vesicular
•  Dermatomal
•  Herald patch
•  Bilateral
•  Unilateral

•  None Reported
•  Tenderness Reported

•  No quadrants tender
•  Right upper quadrant
•  Right lower quadrant
•  Left upper quadrant
•  Left lower quadrant

•  No additional observations
•  Masses
•  Guarding
•  Distention

•  Spinous process nontender to palpation
•  Spinous process tender to palpation
• Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data

•  Accessory muscles nontender to palpation
•  Accessory muscles tender to palpation

•  Tenderness with palpation
•  Non-tender with palpation

•  Expected sensation in proximal and distal
•  Decreased proximal sensation
•  Decreased distal sensation

•  Expected sensation in proximal and distal
•  Decreased proximal sensation
•  Decreased distal sensation

•  Expected sensation
•  Decreased sensation

•  Expected sensation
•  Decreased sensation

•  Expected range of motion (approx. 30 degrees)
•  Reduced extension

•  Expected range of motion (approx. 75-90 degrees)
•  Reduced flexion

•  Expected range of motion bilaterally (approx. 35 degrees)
•  Reduced lateral bending to the right
•  Reduced lateral bending to the left

•  Expected range of motion bilaterally (approx. 30 degrees)
•  Reduced rotation to the right
•  Reduced rotation to the left

Objective Data Collection for Integumentary Evaluation of Felipe Barbosa’s Sick Visit on ShadowHealth
Objective Data Collection: 10 out of 10 (100%)

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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 unusual sounds
– Wheezing
– Fine crackles
– Stridor
– Rhonchi
– Rales

Location (1/3 point)

– All areas clear
– Unusual sounds in the upper right front lobe
– Unusual sounds in the middle right front lobe
– Unusual sounds in the lower right front lobe
– Unusual sounds in the upper left front lobe
– Unusual sounds in the lower left front lobe
– Unusual sounds in the upper right back lobe
– Unusual sounds in the lower right back lobe
– Unusual sounds in the upper left back lobe
– Unusual sounds in the lower left back lobe

Auscultated Heart Sounds
1 of 1 point
Heart Sounds (1/2 point)

– Audible S1 and S2
– Audible S1, S2, and S3
– Audible S1, S2, and S4
– Audible S1, S2, S3, and S4

Extra Heart Sounds (1/2 point)

– No additional sounds
– Gallops
– Murmur
– Friction rub
– Valve clicks

Assessed Location of Rash
1 of 1 point
Location (1/2 point)

– Left side of the torso
– Right side of the torso
– Left side of the back
– Right side of the back
– Left side of the body
– Right side of the 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-blistering
– Blistering
– Follows a nerve distribution
– Herald patch
– On both sides
– On one side

Palpated Abdomen Light
1 of 1 point
Tenderness (1/3 point)

– No reported tenderness
– Reported tenderness

Location Of Tenderness (1/3 point)

– No tender areas
– Tender in the upper right quadrant
– Tender in the lower right quadrant
– Tender in the upper left quadrant
– Tender in the lower left quadrant

Observations (1/3 point)

– No additional observations
– Masses
– Muscle guarding
– Abdominal distention

Palpated Spine
1 of 1 point
Spine Examination (1/2 point)

– Spinous processes not tender on palpation
– Spinous processes tender on palpation

Palpated Spine Accessory Muscles (1/2 point)

– Accessory muscles not tender on palpation
– Accessory muscles tender on palpation

Palpated Rash
1 of 1 point
Palpated Rash (1/1 point)

– Tenderness when palpated
– Not tender when palpated

Tested Sensation in Legs
1 of 1 point
Right Leg Sensation (1/2 point)

– Expected sensation in both proximal and distal areas
– Decreased sensation in proximal area
– Decreased sensation in distal area

Left Leg Sensation (1/2 point)

– Expected sensation in both proximal and distal areas
– Decreased sensation in proximal area
– Decreased sensation in distal area

Tested Sensation in Feet
1 of 1 point
Sensation in Right Foot (1/2 point)

– Expected sensation
– Decreased sensation

Sensation in Left Foot (1/2 point)

– Expected sensation
– Decreased sensation

Tested Spine Range of Motion (ROM)
1 of 1 point
Extension (1/4 point)

– Expected range of motion (approximately 30 degrees)
– Reduced extension

Flexion (1/4 point)

– Expected range of motion (approximately 75-90 degrees)
– Reduced flexion

Lateral Bending (1/4 point)

– Expected range of motion on both sides (approximately 35 degrees)
– Reduced lateral bending to the right
– Reduced lateral bending to the left

Rotation (1/4 point)

– Expected range of motion on both sides (approximately 30 degrees)
– Reduced rotation to the right
– Reduced rotation to the left

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