Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data
Breath Sounds:
– You can hear normal breathing sounds in all areas.
– In some areas, the breathing sounds are not as clear.
– In some areas, there are no breathing sounds at all.
Extra Sounds:
– There are no extra sounds.
– Sometimes, wheezing or crackling sounds are heard, indicating possible issues.
Location:
– The sounds are clear in all areas, except for the front upper right part of the lungs where abnormal sounds are heard.
Checking the Heartbeat
When checking Felipe’s heartbeat, here’s what you find:
Heart Sounds:
– You can hear the regular “lub-dub” sounds (S1 and S2).
– Sometimes, an extra sound called S3 or S4 can be heard.
Extra Heart Sounds:
– No extra sounds are heard.
– Occasionally, additional sounds like murmurs or gallops are present, suggesting potential heart problems.
Examining the Rash Location
When looking at where the rash is, here’s what you see:
Position:
– The rash is on the left or right side of the torso, back, or body.
– It can also be on specific areas like the cervical, thoracic, or lumbar regions.
Characteristics:
– The rash might be clustered, vesicular (with blisters), or non-vesicular.
– It could also be bilateral (on both sides) or unilateral (only on one side).
Checking the Abdomen and Spine
When feeling Felipe’s abdomen and spine, here’s what you find:
Abdomen Tenderness:
– There is no reported tenderness, but sometimes tenderness is felt in specific areas like the upper or lower right or left parts.
Observations:
– Apart from tenderness, you might notice masses, guarding (tightening of muscles), or distention (swelling).
Palpating the Spine:
– The spine’s bony parts are usually not tender, but sometimes they can be.
– Accessory muscles around the spine might also be tender at times.
Feeling the Rash:
– The rash might be tender or non-tender when touched.
Testing Sensation and Movement
Testing Sensation in Legs and Feet:
– Sensation in the legs and feet is usually as expected, but sometimes it’s reduced.
Testing Spine Range of Motion:
– The spine usually moves as expected, but sometimes there’s reduced movement in certain directions like bending or rotating.
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Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data
- Present in all areas
- Diminished in some areas
- Absent in some areas
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
- All areas clear
- Adventitious sounds in anterior right upper lobe
- Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data
- 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
- S1 and S2 audible
- S1, S2, and S3 audible
- S1, S2, and S4 audible
- S1, S2, S3, and S4 audible
- No extra sounds
- Gallops
- Murmur
- Friction rub
- Valve clicks
- Left side of torso
- Right side of torso
- Left side of back
- Right side of back
- Left side of body
- Right side of body
- Cervical
- Thoracic
- Lumbar
- Sacral
- Coccygeal
- Clustered
- Satellite
- Non-vesicular
- Vesicular
- Dermatomal
- Herald patch
- Bilateral
- Unilateral
- None Reported
- Tenderness Reported
- No quadrants tender
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
- No additional observations
- Masses
- Guarding
- Distention
- Spinous process nontender to palpation
- Spinous process tender to palpation
- Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data
- Accessory muscles nontender to palpation
- Accessory muscles tender to palpation
- Tenderness with palpation
- Non-tender with palpation
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
- Expected sensation in proximal and distal
- Decreased proximal sensation
- Decreased distal sensation
- Expected sensation
- Decreased sensation
- Expected sensation
- Decreased sensation
- Expected range of motion (approx. 30 degrees)
- Reduced extension
- Expected range of motion (approx. 75-90 degrees)
- Reduced flexion
- Expected range of motion bilaterally (approx. 35 degrees)
- Reduced lateral bending to the right
- Reduced lateral bending to the left
- Expected range of motion bilaterally (approx. 30 degrees)
- Reduced rotation to the right
- Reduced rotation to the left