Shoshanna Tillman Shadow Health Objective Data

Shoshanna Tillman Shadow Health Objective Data

The doctor listened to the sounds of the heart.
You can earn half a point for this.
Here are the points you can earn for different heart sounds:
– You can hear the first and second heart sounds.
– You can hear the first, second, and third heart sounds.
– You can hear the first, second, and fourth heart sounds.
– You can hear the first, second, third, and fourth heart sounds.

Extra sounds in the heart can earn you half a point:
– If there are no extra sounds, you get no extra points.
– If there are gallops, murmurs, friction rubs, or valve clicks, you get half a point.

The doctor also listened to the sounds of breathing.
You can earn one point for this.
Here are the points you can earn for different breath sounds:
– You get one-third of a point if the breathing sounds are clear everywhere.
– You get one-third of a point if the breathing sounds are diminished in some areas.
– You get one-third of a point if the breathing sounds are absent in some areas.

Extra or unusual breathing sounds can also earn you one-third of a point:
– If there are no extra sounds, you get no extra points.
– If there are wheezing, fine crackles, stridor, rhonchi, or rales, you get one-third of a point.

The location of these sounds can also earn you one-third of a point:
– If all areas are clear, you get one-third of a point.
– If there are unusual sounds in specific parts of the chest, you get one-third of a point.

Then there’s a section about examining Shoshanna Tillman’s eyes, mouth, skin, and other body parts. You can earn points based on what you observe during the examination.

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
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

Integumentary Felipe Barbosa Sick Visit ShadowHealth Objective Data

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

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