Shoshanna Tillman Shadow Health Objective Data

Shoshanna Tillman Shadow Health Objective Data

Auscultated Heart Sounds
– Heart Sounds
– S1 and S2 audible
– S1, S2, and S3 audible
– S1, S2, and S4 audible
– S1, S2, S3, and S4 audible

Extra Heart Sounds
– No extra sounds
– Gallops
– Murmur
– Friction rub
– Valve clicks

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Auscultated Breath Sounds
– Breath Sounds
– Clear in all areas
– Diminished in some areas
– Absent in some areas
– Adventitious Sounds
– No adventitious sounds
– Wheezing
– Fine crackles
– Stridor
– Rhonchi
– Rales
– Location
– All areas clear
– Adventitious sounds in specific lung lobes

Inspected Eyes
– Orbital Area
– No visible abnormal findings
– Ptosis
– Eyelid edema
– Lesion
– Sclera
– White
– Yellow tint
– Redness
– Conjunctiva
– Moist and pink
– Dry appearance
– Redness
– Swelling
– Conjunctival Discharge
– No discharge
– Clear, watery discharge
– Purulent discharge

Inspected Mouth
– Oral Mucosa
– Moist and pink
– Dry appearance
– Redness

Inspected Skin, Hair, and Nails
– Skin
– No visible abnormal findings
– Edema
– Redness
– Rash
– Moles
– Masses
– Freckles, birthmarks, or other discoloration
– Excessive dry or flaking skin
– Purpura
– Scarring
– Laceration, lesion, or wound
– Bruising
– Hair
– No visible abnormal findings
– Balding or hair thinning
– Dandruff
– Scalp discoloration
– Nails
– No visible abnormal findings
– Pallor
– Cyanosis
– Reperfusion
– Splinter hemorrhages
– Grooves
– Fungus
– Peeling
– Clubbing

Inspected Hands and Wrists
– Hands
– No visible abnormal findings
– Redness
– Moles or skin tags
– Masses
– Freckles, birthmarks, or other discoloration
– Excessive dry or flaking skin
– Purpura
– Scarring
– Laceration, lesion, or wound
– Bruising
– Rash
– Wrists
– No visible abnormal findings
– Swelling
– Visible mass
– Irregular alignment
– Discoloration
– Atrophy
– Hypertrophy
– Joint deformity

Inspected Lower Extremities
– Appearance
– No visible abnormal findings
– Discoloration
– Edema
– Skin thickening
– Ulceration
– Varicose veins
– Visible distortion or swelling

Palpated Thyroid
– Observations
– No palpable abnormal findings
– Nodules
– Enlarged
– Irregular
– Tenderness
– None reported
– Tenderness reported

Palpated Upper Extremities
– Right Forearm
– No abnormal findings
– Pitting edema
– Tenderness
– Warmth
– Left Forearm
– No abnormal findings
– Pitting edema
– Tenderness
– Warmth
– Right Upper Arm
– No abnormal findings
– Pitting edema
– Tenderness
– Warmth
– Left Upper Arm
– No abnormal findings
– Pitting edema
– Tenderness
– Warmth

Palpated Lower Extremities
– Right Calf
– No abnormal findings
– Pitting edema
– Tenderness
– Warmth
– Left Calf
– No abnormal findings
– Pitting edema
– Tenderness
– Warmth
– Right Ankle
– No abnormal findings
– Pitting edema
– Tenderness
– Warmth
– Left Ankle
– No abnormal findings
– Pitting edema
– Tenderness
– Warmth
– Right Foot
– No abnormal findings
– Pitting edema
– Tenderness
– Warmth
– Left Foot
– No abnormal findings
– Pitting edema
– Tenderness
– Warmth

Palpated Finger and Wrist Joints
– Right Hand Observations
– No palpable abnormal findings
– Palpable abnormal findings
– Right Hand Tenderness
– None reported
– Tenderness reported
– Left Hand Observations
– No palpable abnormal findings
– Palpable abnormal findings
– Left Hand Tenderness
– None reported
– Tenderness reported

Palpated Radial Pulses
– Right Radial Pulse
– 2+ Normal
– 1+ Diminished
– 0 Absent
– Left Radial Pulse
– 2+ Normal
– 1+ Diminished
– 0 Absent

Various Tests and Observations for Strength and Sensation in Different Body Parts are conducted and recorded.

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