Maya Parker Ear Pain Shadow Health Objective Data Collection

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

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

•  Symmetric
•  Asymmetric

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

•  Moist
•  Dry

•  Pink
•  Erythema

•  Erythemic
•  Cobblestone appearance
•  Exudate
•  Pink

•  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

•  Absent
•  Hypoactive
•  Normoactive
•  Hyperactive

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

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

•  Regular rate
•  Irregular rate

•  Regular Rhythm
•  Irregular Rhythm

•  Accessory muscle use
•  No distress

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

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

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

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

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

•  No visible abnormalities
•  Bruising
•  Deformity
•  Erythema

•  No visible abnormalities
•  Bruising
•  Deformity
•  Erythema

•  Non-tender
•  Tender

•  Non-tender
•  Tender

•  Bluish
•  Red
•  Pink

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

•  Decreased patency
•  Not patent
•  Patent

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

•  Erythema
•  No visible abnormal findings
•  Pallor

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

•  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

•  7:00
•  Cone of light distorted

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

•  Erythema
•  No visible abnormal findings
•  Pallor

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

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

•  5:00
•  Cone of light distorted

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

•  Immobile
•  Mobile

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

Objective Data Collection for Maya Parker’s Ear Pain

Objective Data Collection: 13.5 of 14 (96.0%)

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1. Assess Pain
– Pain assessment is essential to understand the level of discomfort the patient is experiencing.
– Scale:
– 0 – No Hurt
– 2 – Hurts Little Bit
– 4 – Hurts Little More
– 6 – Hurts Even More
– 8 – Hurts Whole Lot
– 10 – Hurts Worse

2. Inspect Head
– Head appearance is important in the examination.
– Criteria: Symmetric or Asymmetric

3. Inspect Face
– Facial appearance is observed for any abnormalities.
– Criteria: Symmetric or Asymmetric

4. Inspect Neck
– The neck is examined for visible abnormal findings.
– Criteria: No visible abnormal findings, Swelling, Visible pulsation, Visible mass

5. Examine Mouth
– Examination of the oral mucosa, color, and other factors.
– Oral Mucosa Appearance: Moist or Dry
– Oral Mucosa Color: Pink or Erythema
– Posterior Oropharynx: Erythemic, Cobblestone appearance, Exudate, Pink
– Tonsils (No point): Various levels of tonsil size

6. Auscultate Abdomen
– Assessment of bowel sounds.
– Bowel Sounds: Absent, Hypoactive, Normoactive, Hyperactive

7. Auscultate Heart
– Evaluation of heart sounds, rate, rhythm, and extra heart sounds.
– 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

8. Auscultate Lungs
– Lung assessment includes appearance, symmetry, breath sounds, and adventitious sounds.
– Appearance: Accessory muscle use or No distress
– Symmetry: Symmetrical chest rise and fall or 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

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

10. Inspect Auricles
– Examination of auricles for abnormalities.
– Left Auricle: No visible abnormalities, Bruising, Deformity, Erythema
– Right Auricle: No visible abnormalities, Bruising, Deformity, Erythema

11. Palpate Auricles
– Palpation of auricles for tenderness.
– Right Ear Palpation: Non-tender, Tender
– Left Ear Palpation: Non-tender, Tender

12. Inspect Nose
– Assessment of nose color, discharge, turbinate patency, and other observations.
– 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

13. Inspect Inner Ears
– Examination of the inner ears, including auditory canal and tympanic membrane.
– 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 (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

14. Inspect Mobility of Tympanic Membranes
– Evaluation of the mobility of tympanic membranes in both ears.
– Left: Immobile or Mobile
– Right: Immobile or Mobile

This detailed objective data collection is crucial for assessing Maya Parker’s ear pain and ensuring an accurate diagnosis and treatment.

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