NR 509 Comprehensive Assessment | objective( Complete Solution Rated A)

Your Results LLaabb PPaassss Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these examinations as essential components of objective data c ...

Your Results LLaabb PPaassss Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these examinations as essential components of objective data collection for this patient. Patient Data Not Scored Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient's case. HEENT Inspected head and neck Scattered pustules on face and facial hair on upper 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 scalp No masses Objective Data Collection: 71.0 of 73 (97.3%) Overview Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam Self-Reflection Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips. 6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 2/10 Palpated sinuses No frontal sinus tenderness No maxillary sinus tenderness Palpated jaw No clicks, full ROM Palpated lymph nodes No axillary lymphadenopathy No supraclavicular lymphadenopathy Palpated thyroid Thyroid smooth without nodules, no goiter 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 Tested eye movements Normal convergence EOMs intact bilaterally, no nystagmus Tested peripheral vision Peripheral vision intact in both eyes, all fields 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 6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 3/10 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 Respiratory Tested pulse oximetry Oxygen saturation 99% Tested lung capacity FVC is 3.91 L and FEV1/FVC ratio is 80.56% Inspected chest wall Anterior chest wall symmetric, no deformity or lesions Posterior chest wall symmetric, no deformity or lesions Palpated thoracic expansion Thoracic expansion symmetric 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 Left lower chest: resonant Right lower chest: resonant 6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 4/10 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 Cardiovascular 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+ 6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 5/10 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 aortic area with the bell: no S3, S4 Auscultated aortic area with the diaphragm: RRR, S1, S2, no murmur 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 Erb's point with the bell: no S3, S4 Auscultated Erb's point 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 Performed Capillary Refill Capillary Refill < 3 sec Inspected for edema Left leg: no edema Right leg: no edema Gastrointestinal 6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 6/10 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 Auscultated arterial sounds Aortic artery: no bruit 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 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