Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data

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

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
  • 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
 Auscultated Heart Sounds
1 of 1 point
Heart Sounds (1/2 point)
  •  S1 and S2 audible
  •  S1, S2, and S3 audible
  •  S1, S2, and S4 audible
  •  S1, S2, S3, and S4 audible
Extra Heart Sounds (1/2 point)
  •  No extra sounds
  •  Gallops
  •  Murmur
  •  Friction rub
  •  Valve clicks
 Assessed Location of Rash
1 of 1 point
Plane (1/2 point)
  •  Left side of torso
  •  Right side of torso
  •  Left side of back
  •  Right side of back
  •  Left side of body
  •  Right side of body
Dermatome (1/2 point)
  •  Cervical
  •  Thoracic
  •  Lumbar
  •  Sacral
  •  Coccygeal
 Assessed Character of Rash
1 of 1 point
Character Of Rash (1/1 point)
  •  Clustered
  •  Satellite
  •  Non-vesicular
  •  Vesicular
  •  Dermatomal
  •  Herald patch
  •  Bilateral
  •  Unilateral
 Palpated Abdomen Light
1 of 1 point
Tenderness (1/3 point)
  •  None Reported
  •  Tenderness Reported
Location Of Tenderness (1/3 point)
  •  No quadrants tender
  •  Right upper quadrant
  •  Right lower quadrant
  •  Left upper quadrant
  •  Left lower quadrant
Observations (1/3 point)
  •  No additional observations
  •  Masses
  •  Guarding
  •  Distention
 Palpated Spine
1 of 1 point
Palpated Spine (1/2 point)
  •  Spinous process nontender to palpation
  •  Spinous process tender to palpation
  • Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data
Palpated Spine Accessory Muscles (1/2 point)
  •  Accessory muscles nontender to palpation
  •  Accessory muscles tender to palpation
 Palpated Rash
1 of 1 point
Palpated Rash (1/1 point)
  •  Tenderness with palpation
  •  Non-tender with palpation
 Tested Sensation in Legs
1 of 1 point
Right Touch (1/2 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal sensation
Left Touch (1/2 point)
  •  Expected sensation in proximal and distal
  •  Decreased proximal sensation
  •  Decreased distal 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
 Tested Spine ROM
1 of 1 point
Extension (1/4 point)
  •  Expected range of motion (approx. 30 degrees)
  •  Reduced extension
Flexion (1/4 point)
  •  Expected range of motion (approx. 75-90 degrees)
  •  Reduced flexion
Lateral Bending (1/4 point)
  •  Expected range of motion bilaterally (approx. 35 degrees)
  •  Reduced lateral bending to the right
  •  Reduced lateral bending to the left
Rotation (1/4 point)
  •  Expected range of motion bilaterally (approx. 30 degrees)
  •  Reduced rotation to the right
  •  Reduced rotation to the left