Shoshanna Tillman Shadow Health Objective Data

•  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

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•  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

Shoshanna Tillman Shadow Health Objective Data Collection: 20 of 21 (95.24%)

Auscultated Heart Sounds
– Heart Sounds: S1 and S2 audible
– Extra Heart Sounds: No extra sounds

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Auscultated Breath Sounds
– Breath Sounds: Clear in all areas
– Adventitious Sounds: No adventitious sounds
– Location: All areas clear

Inspected Eyes
– Orbital Area: No visible abnormal findings
– Sclera: White
– Conjunctiva: Moist and pink
– Conjunctival Discharge: No discharge

Inspected Mouth
– Oral Mucosa: Moist and pink

Inspected Skin, Hair, and Nails
– Skin: No visible abnormal findings
– Hair: No visible abnormal findings
– Nails: No visible abnormal findings

Inspected Hands and Wrists
– Hands: No visible abnormal findings
– Wrists: No visible abnormal findings

Inspected Lower Extremities
– Appearance: No visible abnormal findings

Palpated Thyroid
– Observations: No palpable abnormal findings
– Tenderness: None reported

Palpated Upper Extremities
– Right Forearm: No abnormal findings
– Left Forearm: No abnormal findings
– Right Upper Arm: No abnormal findings
– Left Upper Arm: No abnormal findings

Palpated Lower Extremities
– Right Calf: No abnormal findings
– Left Calf: No abnormal findings
– Right Ankle: No abnormal findings
– Left Ankle: No abnormal findings
– Right Foot: No abnormal findings
– Left Foot: No abnormal findings

Palpated Finger and Wrist Joints
– Right Hand Observations: No palpable abnormal findings
– Left Hand Observations: No palpable abnormal findings

Palpated Radial Pulses
– Right Radial Pulse: 2+ Normal
– Left Radial Pulse: 2+ Normal

Finklestein’s Test
– Right Hand: Negative
– Left Hand: Negative

Tinel’s Test
– Right Hand: Negative
– Left Hand: Negative

Phalen’s Test
– Right Hand: Negative
– Left Hand: Negative

OK Sign Test
– Right Hand: Negative
– Left Hand: Negative

Tested Wrist and Fingers ROM
– Left Wrist: Normal (5 – Active movement against full resistance without fatigue)
– Right Wrist: Normal (5 – Active movement against full resistance without fatigue)
– Left Hand Fingers: Normal (5 – Active movement against full resistance without fatigue)
– Right Hand Fingers: Normal (5 – Active movement against full resistance without fatigue)

Tested Squeezing Strength
– Left Hand Fingers: Normal (5 – Active movement against full resistance without fatigue)
– Right Hand Fingers: Normal (5 – Active movement against full resistance without fatigue)

Tested Pushing Strength
– Left Hand Fingers: Normal (5 – Active movement against full resistance without fatigue)
– Right Hand Fingers: Normal (5 – Active movement against full resistance without fatigue)

Tested Sensation in Hands
– Right: Expected sensation
– Left: Expected sensation

Tested Sensation in Feet
– Right: Expected sensation
– Left: Expected sensation

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