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Complete Comprehensive Assessment Objective Shadow Health

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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 with ophthalmoscope Mild retinopathic changes on right 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

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lOMoARcPSD|27916040




Complete Comprehensive Assessment
Objective Shadow Health

, Health Assessment Of Individuals Across
The Lifespan (University of North Florida)

, lOMoARcPSD|27916040




1-8-2024

Comprehensive Assessment Results | Turned In
Nursing 562/562L Advanced Health Assessment
(




Overvie
Objective Data Collection: 69 of 73 (94.5%)
w

Transcri

pt
Subjective Data
Hover To Reveal... Indicates an item that you found.
Collection Objective Indicates an item that is available to be
Hover over the Patient Data found.
Data Collection items below to reveal important
information, including Pro
Documentation Tips.

Plan My Exam

Program Competency Category Scored Items Patient Data
Progress Not Scored
Experts selected these examinations as
essential components of objective data Thorough examinations will yield better
collection for this patient. patient data The following actions reveal
the objective data of th 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


Palpated sinuses No frontal sinus
tenderness No maxillary
sinus tenderness


Palpated jaw No clicks, full ROM


Palpated lymph nodes No axillary lymphadenopathy

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