Shoshanna Tillman Shadow Health Objective Data Collection: 20 of 21 (95.24%)
- Correct
- Partially correct
- Incorrect
- Missed
Auscultated Heart Sounds
0.5 of 1 point
Heart Sounds (No point)
- S1 and S2 audible
- S1, S2, and S3 audible
- S1, S2, and S4 audible
- S1,S2, S3, and S4 audible
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Extra Heart Sounds (1/2 point)
- No extra sounds
- Gallops
- Murmur
- Friction rub
- Valve clicks
Auscultated Breath Sounds
1 of 1 point
Breath Sounds (1/3 point)
- Clear in all areas
- Diminished in some areas
- Absent in some areas
Adventitious Sounds (1/3 point)
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
Location (1/3 point)
- 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
Inspected Eyes
1 of 1 point
Orbital Area (1/4 point)
- No visible abnormal findings
- Ptosis
- Eyelid edema
- Lesion
Sclera (1/4 point)
- White
- Yellow tint
- Redness
Conjunctiva (1/4 point)
- Moist and pink
- Dry appearance
- Redness
- Swelling
Conjunctival Discharge (1/4 point)
- No discharge
- Clear, watery discharge
- Purulent discharge
Inspected Mouth
1 of 1 point
Oral Mucosa (1/1 point)
- Moist and pink
- Dry appearance
- Redness
Inspected Skin, Hair, and Nails
1 of 1 point
Skin (1/3 point)
- 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
Hair (1/3 point)
- No visible abnormal findings
- Balding or hair thinning
- Dandruff
- Scalp discoloration
Nails (1/3 point)
- No visible abnormal findings
- Pallor
- Cyanosis
- Reperfusion
- Splinter hemorrhages
- Grooves
- Fungus
- Peeling
- Clubbing
Inspected Hands and Wrists
1 of 1 point
Hands (1/2 point)
- 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
Wrists (1/2 point)
- No visible abnormal findings
- Swelling
- Visible mass
- Irregular alignment
- Discoloration
- Atrophy
- Hypertrophy
- Joint deformity
Inspected Lower Extremities
1 of 1 point
Appearance (1/1 point)
- No visible abnormal findings
- Discoloration
- Edema
- Skin thickening
- Ulceration
- Varicose veins
- Visible distortion or swelling
Palpated Thyroid
1 of 1 point
Observations (1/2 point)
- No palpable abnormal findings
- Nodules
- Enlarged
- Irregular
Tenderness (1/2 point)
- None reported
- Tenderness reported
Palpated Upper Extremities
1 of 1 point
Right Forearm (1/4 point)
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
Left Forearm (1/4 point)
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
Right Upper Arm (1/4 point)
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
Left Upper Arm (1/4 point)
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
Palpated Lower Extremities
1 of 1 point
Right Calf (1/6 point)
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
Left Calf (1/6 point)
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
Right Ankle (1/6 point)
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
Left Ankle (1/6 point)
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
Right Foot (1/6 point)
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
Left Foot (1/6 point)
- No abnormal findings
- Pitting edema
- Tenderness
- Warmth
Palpated Finger and Wrist Joints
0.5 of 1 point
Right Hand Observations (1/4 point)
- No palpable abnormal findings
- Palpable abnormal findings
Right Hand Tenderness (No point)
- None reported
- Tenderness reported
Left Hand Observations (1/4 point)
- No palpable abnormal findings
- Palpable abnormal findings
Left Hand Tenderness (No point)
- None reported
- Tenderness reported
Palpated Radial Pulses
1 of 1 point
Right Radial Pulse (1/2 point)
- 2+ Normal
- 1+ Diminished
- 0 Absent
Left Radial Pulse (1/2 point)
- 2+ Normal
- 1+ Diminished
- 0 Absent
Finklestein’s Test
1 of 1 point
Right Hand (1/2 point)
- Positive
- Negative
Left Hand (1/2 point)
- Positive
- Negative
Tinel’s Test
1 of 1 point
Right Hand (1/2 point)
- Positive
- Negative
Left Hand (1/2 point)
- Postive
- Negative
Phalen’s Test
1 of 1 point
Right Hand (1/2 point)
- Positive
- Negative
Left Hand (1/2 point)
- Positive
- Negative
OK Sign Test
1 of 1 point
Right Hand (1/2 point)
- Positive
- Negative
Left Hand (1/2 point)
- Positive
- Negative
Tested Wrist and Fingers ROM
1 of 1 point
Left Wrist (1/4 point)
- 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)
Right Wrist (1/4 point)
- 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)
Left Hand Fingers (1/4 point)
- 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
Right Hand Fingers (1/4 point)
- 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)
Tested Squeezing Strength
1 of 1 point
Left Hand Fingers (1/2 point)
- 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)
Right Hand Fingers (1/2 point)
- 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)
Tested Pushing Strength
1 of 1 point
Left Hand Fingers (1/2 point)
- 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
Right Hand Fingers (1/2 point)
- 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)
Tested Sensation in Hands
1 of 1 point
Right (1/2 point)
- Expected sensation
- Decreased sensation
Left (1/2 point)
- Expected sensation
- Decreased sensation
Tested Sensation in Feet
1 of 1 point
Right (1/2 point)
- Expected sensation
- Decreased sensation
Left (1/2 point)
- Expected sensation
- Decreased sensation
- Shoshanna Tillman Shadow Health Objective Data