Comprehensive Assessment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Your Results
Lab Pass
Overview Objective Data Collection: 71.0 of 73 (97.3%)
Transcript
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Subjective Data Collection
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Objective Data Collection below to reveal important information, found.
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Documentation
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Category Scored Items Patient Data
Self-Reflection
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Experts selected these examinations as
essential components of objective data Thorough examinations will yield better patient
collection for this 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
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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 Mild retinopathic changes on right
with ophthalmoscope 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
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Left TM intact and pearly gray, positive
light reflex
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