Tina Jones HEENT Shadow Health Objective Data

Uncategorized

Objective Data Collection: 24.42 of 25 (97.68%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed
 Inspected head and face
0.67 of 1 point
Skull Symmetry (1/3 point)
  •  Symmetric
  •  Asymmetric
Facial Feature Symmetry (1/3 point)
  •  Symmetric
  •  Asymmetric
Appearance (No point)
  •  No visible abnormal findings
  •  Rash
  •  Papules, pustules, or comedones
  •  Skin growths (freckles, moles, or birthmarks)
  •  Excessive hair growth
  •  Evidence of skin trauma (scar, laceration, or bruising)
  •  Red, chapped nose
 Inspected eyes and orbital area
1 of 1 point
Orbital Area (1/4 point)
  •  No visible abnormal findings
  •  Ptosis
  •  Eyelid edema
  •  Lesion
  •  Allergic shiners
Sclera (1/4 point)
  •  White
  •  Injection
  •  Icterus
Conjunctiva (1/4 point)
  •  Moist and pink
  •  Pale
  •  Dry appearance
  •  Erythema
  •  Edema
Conjunctival Discharge (1/4 point)
  •  No discharge
  •  Clear, watery discharge
  •  Purulent discharge
 Inspected nasal cavities
0.75 of 1 point
Color (No point)
  •  Pink
  •  Pale
  •  Erythemic
  •  Bluish
Discharge (1/4 point)
  •  No discharge
  •  Clear discharge
  •  Bloody discharge
  •  Purulent discharge
Turbinate Patency (1/4 point)
  •  Patent
  •  Decreased patency
  •  Not patent
Observations (1/4 point)
  •  No additional visible abnormal findings
  •  Foreign body present
  •  Polyp
  •  Septum perforated
  •  Septum deviated
  •  Lesion
 Inspected ears
1 of 1 point
Right: Auditory Canal Color (1/10 point)
  •  Pink
  •  Red
  •  Pallor
Right: Tympanic Membrane Color (1/10 point)
  •  Pearly gray
  •  Red
  •  Opaque
  •  Yellow
  •  Not visible because of cerumen
Right: Tympanic Membrane Appearance (1/10 point)
  •  No visible abnormal findings
  •  Fluid observed
  •  Visible scars
  •  Bulging
  •  Perforation
  •  Retraction
Right: Cone Of Light (1/10 point)
  •  5:00
  •  Cone of light distorted
Right: Discharge (1/10 point)
  •  No discharge
  •  Cerumen
  •  Clear discharge
  •  Bloody discharge
  •  Purulent discharge
Left: Auditory Canal Color (1/10 point)
  •  Pink
  •  Red
  •  Pallor
Left: Tympanic Membrane Color (1/10 point)
  •  Pearly gray
  •  Red
  •  Opaque
  •  Yellow
  •  Not visible because of cerumen
Left: Tympanic Membrane Appearance (1/10 point)
  •  No visible abnormal findings
  •  Fluid observed
  •  Visible scars
  •  Bulging
  •  Perforation
  •  Retraction
Left: Cone Of Light (1/10 point)
  •  7:00
  •  Cone of light distorted
Left: Discharge (1/10 point)
  •  No discharge
  •  Cerumen
  •  Clear discharge
  •  Bloody discharge
  •  Purulent discharge
 Inspected mouth and throat
1 of 1 point
Oral Mucosa (1/6 point)
  •  Moist and pink
  •  Dry appearance
  •  Erythemic
Tonsils (1/6 point)
  •  No visible abnormal findings
  •  Edema
  •  Erythema
Tonsil Grade (1/6 point)
  •  0: Tonsils fit within tonsillar fossa
  •  1+: Tonsils <25% of space between pillars
  •  2+: Tonsils <50% of space between pillars
  •  3+: Tonsils <75% of space between pillars
  •  4+: Tonsils >75% of space between pillars
Posterior Oropharynx Color (1/6 point)
  •  Pink
  •  Erythemic
Posterior Oropharynx Texture (1/6 point)
  •  No abnormal findings
  •  Cobblestoning
  •  Exudate
Post Nasal Drip (1/6 point)
  •  No discharge
  •  Clear discharge
  •  Purulent discharge
 Inspected neck
1 of 1 point
Symmetry (1/2 point)
  •  Symmetric
  •  Asymmetric
Appearance (1/2 point)
  •  No visible abnormal findings
  •  Swelling
  •  Visible pulsation
  •  Visible mass
  •  Discoloration
 Palpated scalp
1 of 1 point
Tenderness (1/2 point)
  •  None reported
  •  Tenderness reported
Observations (1/2 point)
  •  No additional abnormal findings
  •  Balding or thinning areas in hair distribution
  •  Palpable masses
 Palpated sinuses
1 of 1 point
Frontal (1/2 point)
  •  None reported
  •  Tenderness reported
Maxillary (1/2 point)
  •  None reported
  •  Tenderness reported
 Palpated temporal arteries
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Intensity (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Intensity (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated carotid arteries
1 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Intensity (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
Left: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Left: Intensity (1/4 point)
  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse
 Palpated jaw
1 of 1 point
Observations (1/1 point)
  •  No palpable abnormal findings
  •  Limited range of motion
  •  Popping or clicking
 Palpated lymph nodes
1 of 1 point
Head And Neck (1/3 point)
  •  No palpable nodes
  •  Palpable nodes on right side
  •  Palpable nodes on left side
Supraclavicular (1/3 point)
  •  No palpable nodes
  •  Palpable nodes on right side
  •  Palpable nodes on left side
Axillary (1/3 point)
  •  No palpable nodes
  •  Palpable nodes on right side
  •  Palpable nodes on left side
 Palpated thyroid gland
1 of 1 point
Observations (1/2 point)
  •  No palpable abnormal findings
  •  Nodules
  •  Enlarged
  •  Irregular
Tenderness (1/2 point)
  •  None reported
  •  Tenderness reported
 Auscultated breath sounds
1 of 1 point
Breath Sounds (1/3 point)
  •  Present 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
 Auscultated temporal arteries
1 of 1 point
Right (1/2 point)
  •  No bruit
  •  Bruit
Left (1/2 point)
  •  No bruit
  •  Bruit
 Auscultated carotid arteries
1 of 1 point
Right (1/2 point)
  •  No bruit
  •  Bruit
Left (1/2 point)
  •  No bruit
  •  Bruit
 Tested pupillary reaction
1 of 1 point
Observations With Penlight (1/1 point)
  •  No visible abnormal findings (PERRL)
  •  Unequal
  •  Irregular
  •  Miosis
  •  Mydriasis
  •  Non-reactive to light
 Tested extraocular eye movements
1 of 1 point
Cardinal Fields (1/2 point)
  •  No visible abnormal findings
  •  Nystagmus
  •  Fixed pupil
Convergence (1/2 point)
  •  No visible abnormal findings
  •  Unequal bilaterally
  •  Fixed pupil
 Tested peripheral vision
1 of 1 point
Observations (1/1 point)
  •  No abnormal findings
  •  Reduced right visual field
  •  Reduced left visual field
 Examined fundus with ophthalmoscope
1 of 1 point
Right: Retina (1/4 point)
  •  No visible abnormal findings
  •  Myelinated nerve fibers
  •  Papilledema
  •  Glaucomatous cupping
  •  Drusen bodies
  •  Cotton wool bodies
  •  Hemorrhage
Right: Disc Margin (1/4 point)
  •  Sharp
  •  Blurred
Left: Retina (1/4 point)
  •  No visible abnormal findings
  •  Myelinated nerve fibers
  •  Papilledema
  •  Glaucomatous cupping
  •  Drusen bodies
  •  Cotton wool bodies
  •  Hemorrhage
Left: Disc Margin (1/4 point)
  •  Sharp
  •  Blurred
 Tested visual acuity
1 of 1 point
Right (1/2 point)
  •  20/100
  •  20/70
  •  20/50
  •  20/40
  •  20/30
  •  20/25
  •  20/20
  •  20/15
  •  20/13
  •  20/10
Left (1/2 point)
  •  20/100
  •  20/70
  •  20/50
  •  20/40
  •  20/30
  •  20/25
  •  20/20
  •  20/15
  •  20/13
  •  20/10
 Performed Weber test
1 of 1 point
Results (1/1 point)
  •  Normal
  •  Conductive or sensorineural loss
 Performed Rinne test
1 of 1 point
Right (1/2 point)
  •  Normal
  •  Conductive loss
Left (1/2 point)
  •  Normal
  •  Conductive loss
 Performed whisper test
1 of 1 point
Right (1/2 point)
  •  Normal
  •  Unable to hear whispered words
Left (1/2 point)
  •  Normal
  •  Unable to hear whispered words
 Tested gag reflex
1 of 1 point
Observations (1/1 point)
  •  Intact
  •  Absent
  •  Hypersensitive