Tina Comprehensive Assessment Shadow Health Objective Questions
Objective Data Collection: 69 of 73 (94.5%)
Categ ory
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Scored Items
Experts selected these examinations as essential components of objective data collection for this patient.
HEENT
Respiratory Cardiovascular
Patient Data
Not Scored
Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient's case.
Gastrointestinal Musculoskeletal
Neurologic
Inspected head and neck Scattered pustules on face and facial hair on upper al
lip
Head is normocephalic, atraumatic Normal scalp hair distribution Acanthosis nigricans noted on neck
Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema
Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema
Palpated sinuses No frontal sinus tenderness No maxillary sinus tenderness
Palpated lymph nodes No axillary lymphadenopathy
No supraclavicular lymphadenopathy
Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, white sclera
Lower eyelids: conjunctiva pink, no lesions, white sclera
Tested PERRL with penlight Right pupil: equal, round, reactive to light Left pupil: equal, round, reactive to light
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Tested eye movements Normal convergence
EOMs intact bilaterally, no nystagmus
Inspected interior eyes with ophthalmoscope Mild retinopathic changes on right
Left fundus with sharp disc margins, no hemorrhages
Tested visual acuity Vision 20/20 right eye with corrective lenses Vision 20/20 left eye with corrective lenses
Examined nasal cavities with otoscope Nasal mucosa moist and pink, septum midline on
right
Nasal mucosa moist and pink, septum midline on left
Examined ear cavities with otoscope Right TM intact and pearly gray, positive light reflex
Left TM intact and pearly gray, positive light reflex
Practiced whisper test Whispered words heard on right Whispered words heard on left
Inspected mouth and throat with tongue blade Oral mucosa moist without ulcerations or lesions,
uvula midline
Gag reflex intact
Inspected chest wall Anterior chest wall symmetric, no deformity or lesions
Posterior chest wall symmetric, no deformity or lesions
Palpated tactile fremitus Anterior upper chest wall: normal fremitus Anterior lower chest wall: normal fremitus Posterior upper chest wall: normal fremitus Posterior middle chest wall: normal fremitus Posterior lower chest wall: normal fremitus
Percussed anterior chest wall Right upper chest: resonant Left upper chest: resonant Left middle chest: resonant Right middle chest: resonant Right lower chest: resonant Left lower chest: resonant
Percussed posterior chest wall Left upper chest: resonant Right upper chest: resonant Right middle chest: resonant Left middle chest: resonant
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Right lower chest: resonant
Auscultated breath sounds of anterior chest wall Right upper lungs: no adventitious sounds
Left upper lungs: no adventitious sounds Left middle lungs: no adventitious sounds Right middle lungs: no adventitious sounds Right lower lungs: no adventitious sounds Left lower lungs: no adventitious sounds
Auscultated breath sounds of posterior chest wall Left upper lungs: no adventitious sounds
Right upper lungs: no adventitious sounds Right middle lungs: no adventitious sounds Left middle lungs: no adventitious sounds Left lower lungs: no adventitious sounds Right lower lungs: no adventitious sounds
Auscultated anterior lungs for bronchophony Right upper lungs: muffled voice sounds
Left upper lungs: muffled voice sounds Left middle lungs: muffled voice sounds Right middle lungs: muffled voice sounds Right lower lungs: muffled voice sounds Left lower lungs: muffled voice sounds
Auscultated posterior lungs for bronchophony Left upper lungs: muffled voice sounds
Right upper lungs: muffled voice sounds Right middle lungs: muffled voice sounds Left middle lungs: muffled voice sounds Left lower lungs: muffled voice sounds Right lower lungs: muffled voice sounds
Palpated pulses of the head and neck Right carotid pulse: 2+, no thrill Left carotid pulse: 2+, no thrill
Palpated PMI PMI palpated at the midclavicular line, 5th intercostal space, no heaves or lifts
Palpated pulses of the upper extremities Right radial pulse: 2+ Right brachial pulse: 2+ Left brachial pulse: 2+ Left radial pulse: 2+
Palpated pulses of the lower extremities Right femoral pulse: 2+ Right popliteal pulse: 2+ Right tibial pulse: 2+
Right dorsalis pedis pulse: 2+ Left femoral pulse: 2+
Left popliteal pulse: 2+ Left tibial pulse: 2+
Left dorsalis pedis pulse: 2+
Auscultated arteries in the head and neck Right carotid artery: no bruit
Left carotid artery: no bruit
Auscultated heart sounds Auscultated Erb's point with the bell: no S3, S4 Auscultated Erb's point with the diaphragm: RRR,
S1, S2, no murmur
Auscultated aortic area with the bell: no S3, S4 Auscultated aortic area with the diaphragm: RRR,
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Auscultated pulmonic area with the bell: no S3, S4 Auscultated pulmonic area with the diaphragm:
RRR, S1, S2, no murmur
Auscultated tricuspid area with the bell: no S3, S4 Auscultated tricuspid area with the diaphragm:
RRR, S1, S2, no murmur
Auscultated mitral area with the bell: no S3, S4 Auscultated mitral area with the diaphragm: RRR,
S1, S2, no murmur
Auscultated arteries of the body Right renal artery: no bruit Right iliac artery: no bruit Right femoral artery: no bruit Left renal artery: no bruit Left iliac artery: no bruit
Left femoral artery: no bruit
Inspected for edema Left leg: no edema Right leg: no edema
Inspected abdomen Abdomen protuberant, symmetric, no visible masses or lesions, coarse hair from pubis to umbilicus
Auscultated bowel sounds Right upper quadrant: normoactive Right lower quadrant: normoactive Left upper quadrant: normoactive Left lower quadrant: normoactive
Percussed CVA tenderness Right flank: none reported Left flank: none reported
Percussed organs Spleen percussion: no dullness Liver span: 7 cm MCL on percussion
Percussed abdomen Right upper quadrant: tympanic Right lower quadrant: tympanic Left lower quadrant: tympanic Left upper quadrant: tympanic
Palpated abdomen - light Right upper quadrant: soft, no tenderness or masses
Right lower quadrant: soft, no tenderness or masses
Left lower quadrant: soft, no tenderness or masses Left upper quadrant: soft, no tenderness or masses
Palpated abdomen - deep Right upper quadrant: no masses, guarding or rebound
Right lower quadrant: no masses, guarding or rebound
Left upper quadrant: no masses, guarding or rebound
Left lower quadrant: no masses, guarding or rebound
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Palpated organs Liver: palpable 1 cm below right costal margin Spleen: not palpable
Right kidney: not palpable, no masses Left kidney: not palpable, no masses
Inspected upper extremities Right shoulder without swelling, masses, or deformity
Right arm without swelling, masses, or deformity Right elbow without swelling, masses, or deformity Right wrist and hand without swelling, masses, or
deformity
Left shoulder without swelling, masses, or deformity
Left arm without swelling, masses, or deformity Left elbow without swelling, masses, or deformity Left wrist and hand without swelling, masses, or
deformity
Fingernails: no ridges or abnormalities in nails, pink nailbeds
Inspected lower extremities Right leg without swelling, masses, or deformity Right knee without swelling, masses, or deformity Right ankle without swelling, masses, deformity, or
discoloration
Right foot without swelling, masses, or deformity Left leg without swelling, masses, or deformity Left knee without swelling, masses, or deformity Left ankle without swelling, masses, or deformity Left foot without swelling, masses, or deformity Toenails: no ridges or abnormalities in nails, pink
nailbeds
Tested ROM for upper extremities Right and left shoulders: full ROM Right and left elbows: full ROM Right and left wrists: full ROM
Tested ROM for spine Rotate left: full ROM Rotate right: full ROM Extension: full ROM Flexion: full ROM
Tested ROM for lower extremities Right and left knees: full ROM Right and left ankles: full ROM
Tested strength for upper extremities Right and left shoulder strength: 5/5 Right and left elbow strength: 5/5 Right and left wrist strength: 5/5 Right and left hand strength: 5/5
Tested strength for lower extremities Right and left knee strength: 5/5 Right and left ankle strength: 5/5
Tested graphesthesia Identified the number "8" drawn on right hand Identified the letter "A" drawn on left hand
Tested sensation in feet with monofilament Decreased sensation in right foot
Decreased sensation in left foot
Tested ability to sense light touch of upper extremities
Right arm proximal light touch sensation intact Right arm distal light touch sensation intact Left arm proximal light touch sensation intact Left arm distal light touch sensation intact
Tested ability to sense light touch of lower extremities
Right leg proximal light touch sensation intact Right leg distal light touch sensation intact Left leg proximal light touch sensation intact Left leg distal light touch sensation intact
Tested ability to sense dull pain in upper extremities
Right arm proximal dull pain sensation intact Right arm distal dull pain sensation intact Left arm proximal dull pain sensation intact Left arm distal dull pain sensation intact
Tested ability to sense dull pain in lower extremities
Right leg proximal dull pain sensation intact Right leg distal dull pain sensation intact Left leg proximal dull pain sensation intact Left leg distal dull pain sensation intact
Tested ability to sense sharp pain in upper extremities
Right arm proximal sharp pain sensation intact Right arm distal sharp pain sensation intact Left arm proximal sharp pain sensation intact Left arm distal sharp pain sensation intact
Tested ability to sense sharp pain in lower extremities
Right leg proximal sharp pain sensation intact Right leg distal sharp pain sensation intact Left leg proximal sharp pain sensation intact Left leg distal sharp pain sensation intact
Tested position sense Position sense intact in toes Position sense intact in fingers
Identified paperclip in right hand within 5 seconds Identified key in right hand within 5 seconds Identified coin in left hand within 5 seconds Identified paperclip in left hand within 5 seconds Identified key in left hand within 5 seconds
Tested deep tendon reflexes of upper extremities Right triceps: 2+
Right biceps: 2+
Right brachioradialis: 2+
Left triceps: 2+
Left biceps: 2+
Left brachioradialis: 2+
Tested deep tendon reflexes of lower extremities Right ankle: 2+
Right knee: 2+
Left knee: 2+
Left ankle: 2+
Tested finger-to-nose coordination Right finger to nose: smooth and accurate Left finger to nose: smooth and accurate
Tested heel-to shin-coordination Right foot straight line down shin, smooth and accurate
Left foot straight line down shin, smooth and accurate [Show Less]