Maureen Hopkins Shadow Health Objective Data

•  Normocephalic and atraumatic
•  Traumatic scalp injury

•  Normal hair distribution
•  Central scalp hair loss
•  Male-pattern hair loss

•  Scalp epidermis intact
•  Scaling of scalp epidermis

•  No visible abnormal findings
•  Allergic shiners
•  Exophthalmos
•  Eyelid edema
•  Lesion
•  Ptosis

•  White
•  Scleral icterus
•  Scleral erythema
•  Injected

•  Moist and pink
•  Pale
•  Dry appearance
•  Erythema
•  Edema
• Maureen Hopkins Shadow health Objective Data

•  No discharge
•  Clear, watery discharge
•  Purulent discharge

•  No visible abnormal findings
•  Allergic shiners
•  Exophthalmos
•  Eyelid edema
•  Lesion
•  Ptosis

•  White
•  Scleral icterus
•  Scleral erythema
•  Injected

•  Moist and pink
•  Pale
•  Dry appearance
•  Erythema
•  Edema

•  No discharge
•  Clear, watery discharge
•  Purulent discharge

•  Pink
•  Red
•  Pallor

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

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

•  Pink
•  Red
•  Pallor

•  No visible abnormal findings
• Maureen Hopkins Shadow health Objective Data
•  Fluid observed
•  Visible scars
•  Bulging
•  Perforation
•  Retraction

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

•  Pink
•  Pale
•  Erythemic
•  Bluish

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

•  Patent
•  Decreased patency
•  Not patent

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

•  Moist and pink
•  Dry appearance
•  Erythemic

•  No visible abnormal findings
•  Edema
•  Erythema

•  Pink
•  Erythemic

•  Skin well hydrated
•  Epidermal flaking noted
•  Extensive dermal scaling noted

•  Skin well hydrated
•  Epidermal flaking noted
•  Extensive dermal scaling noted

•  No goiter appreciated
•  Goiter present

•  Present 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

•  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

•  Cranial nerves II-XII intact
•  Facial asymmetry noted
•  Dysarthria noted
•  Abnormal eye movements noted

•  Expected sensation
•  Decreased sensation

•  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)

•  Hair has normal thickness
•  Hair is thin
•  Hair has excessive thickness

•  Hair intact with palpation
•  Hair falls out with palpation

•  Hair shaft does not break with palpation
•  Hair shaft breaks with palpation

•  No palpable abnormal findings
•  Nodules
•  Enlarged
•  Irregular

•  None reported
•  Tenderness reported

•  Brand name medication listed
•  Generic name medication listed
• Maureen Hopkins Shadow health Objective Data

Maureen Hopkins Shadow Health: Collecting Objective Data – 100% Completion

Inspected Head
1 out of 1 point
Injury Presence (1/3 point)

Normal head shape and no injuries
Injury on the scalp

Hair Distribution (1/3 point)

Normal hair distribution
Hair loss at the center of the scalp
Hair loss pattern like male-pattern baldness

Scalp Skin (1/3 point)

Scalp skin is intact
Scalp skin shows scaling

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Inspected Eyes
1 out of 1 point
Left Eye Orbital Area (1/8 point)

No unusual findings
Allergic shiners
Exophthalmos (bulging eyes)
Swollen eyelids
Lesion present
Drooping eyelid

Left Eye Sclera (1/8 point)

White
Yellowed sclera (jaundice)
Red sclera (inflammation)
Redness in sclera

Left Eye Conjunctiva (1/8 point)

Moist and pink
Pale conjunctiva
Dry conjunctiva
Redness in conjunctiva
Swollen conjunctiva

Left Eye Conjunctival Discharge (1/8 point)

No discharge
Clear, watery discharge
Pus-like discharge

Right Eye Orbital Area (1/8 point)

No unusual findings
Allergic shiners
Exophthalmos
Swollen eyelids
Lesion present
Drooping eyelid

Right Eye Sclera (1/8 point)

White
Yellowed sclera
Red sclera
Redness in sclera

Right Eye Conjunctiva (1/8 point)

Moist and pink
Pale conjunctiva
Dry conjunctiva
Redness in conjunctiva
Swollen conjunctiva

Right Eye Conjunctival Discharge (1/8 point)

No discharge
Clear, watery discharge
Pus-like discharge

Inspected Ears
1 out of 1 point
Left Ear Auditory Canal Color (1/6 point)

Pink
Red
Pale

Left Ear Tympanic Membrane Appearance (1/6 point)

No unusual findings
Fluid presence
Scarring visible
Bulging eardrum
Hole in eardrum
Retracted eardrum

Left Ear Discharge (1/6 point)

No discharge
Earwax
Clear discharge
Bloody discharge
Pus-like discharge

Right Ear Auditory Canal Color (1/6 point)

Pink
Red
Pale

Right Ear Tympanic Membrane Appearance (1/6 point)

No unusual findings
Fluid presence
Scarring visible
Bulging eardrum
Hole in eardrum
Retracted eardrum

Right Ear Discharge (1/6 point)

No discharge
Earwax
Clear discharge
Bloody discharge
Pus-like discharge

Inspected Nose
1 out of 1 point
Color (1/4 point)

Pink
Pale
Red
Bluish

Discharge (1/4 point)

No discharge
Clear discharge
Bloody discharge
Pus-like discharge

Turbinate Patency (1/4 point)

Open airways
Decreased airway openness
Blocked airways

Observations (1/4 point)

No additional unusual findings
Foreign object present
Polyp growth
Perforated septum
Deviated septum
Lesion visible

Inspected Throat
1 out of 1 point
Oral Mucosa (1/3 point)

Moist and pink
Dry appearance
Redness

Tonsils (1/3 point)

No unusual findings
Swollen tonsils
Redness in tonsils

Back Oropharynx Color (1/3 point)

Pink
Red

Inspected Skin, Arms
1 out of 1 point
Left Arm (1/2 point)

Skin well hydrated
Skin peeling observed
Extensive skin scaling seen

Right Arm (1/2 point)

Skin well hydrated
Skin peeling observed
Extensive skin scaling seen

Inspected Thyroid
1 out of 1 point
Thyroid (1/1 point)

No enlarged thyroid
Enlarged thyroid (goiter) present

Auscultated Breath Sounds
1 out of 1 point
Breath Sounds (1/3 point)

Present in all areas
Weakened in some areas
Absent in some areas

Extra Sounds (1/3 point)

No added sounds
Wheezing
Fine crackles
Stridor
Abnormal lung sounds (rhonchi, rales)

Location (1/3 point)

Clear sounds in all areas
Extra sounds heard in specific lung areas

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

Audible S1 and S2 sounds
Audible S1, S2, and S3 sounds
Audible S1, S2, and S4 sounds
Audible S1, S2, S3, and S4 sounds

Extra Heart Sounds (1/2 point)

No additional sounds
Gallops
Murmur
Friction rub
Valve clicks

Assessed Cranial Nerves
1 out of 1 point
Cranial Nerve Examinations (1/1 point)

All cranial nerves (II-XII) normal
Facial asymmetry noted
Speech difficulty (dysarthria) present
Abnormal eye movements detected

Assessed Upper Musculoskeletal Strength
1 out of 1 point
Hand Sensation (1/2 point)

Expected sensation
Reduced sensation

Grip Strength Test (1/2 point)

0 – No muscle contraction
1 – Slight contraction detected
2 – Movement possible against gravity
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)

Assessed Lower Musculoskeletal Strength
1 out of 1 point
Hip Strength (1/1 point)

0 – No muscle contraction
1 – Slight contraction detected
2 – Movement possible against gravity
3 – Active movement against gravity
4 – Active movement against gravity and resistance
5 – Active movement against full resistance without fatigue (normal)

Palpated Hair
1 out of 1 point
Hair Thickness (1/3 point)

Hair is of normal thickness
Hair thinning
Hair thickness is excessive

Hair Condition (1/3 point)

Hair remains intact upon touch
Hair falls out upon touch

Hair Shaft Condition (1/3 point)

Hair shaft does not break when touched
Hair shaft breaks upon touch

Palpated Thyroid
1 out of 1 point
Observations (1/2 point

)

No unusual findings upon palpation
Nodules present
Enlarged thyroid detected
Irregular thyroid shape noticed

Tenderness (1/2 point)

No reported tenderness
Tenderness reported

Checked Medication Bottle
1 out of 1 point
Medication Name (1/1 point)

Brand name medication listed
Generic name medication listed