Tina Comprehensive Assessment Shadow Health Objective Questions
Objective Data Collection: 69 of 73 (94.5%)
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Category HEENT
Scored Items
Respiratory
Experts selected these examinations as
essential components of objective data
Cardiovascular
collection for this patient.
Patient Data Gastrointestinal
Not Scored
Musculoskeletal
Thorough examinations will yield better Neurologic
patient data. The following actions reveal
the objective data of the patient's case.
Inspected head and neck Scattered pustules on face and facial hair on upper al
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
Palpated sinuses No frontal sinus
tenderness No
maxillary sinus
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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
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