Shadow Health - Esther Park - Cognition – Objective (2022/2023) Graded A+

Shadow Health - Esther Park - Cognition – Objective (2022/2023) Graded A+ Assessed Vitals Temperature: normothermic Blood Pressure: hypertensive Heart Rate: no abnormal findings Respiratory Rate: no abnormal findings O2 Saturation: no abnormal findings Assessed IV Bag Appropriate Fluid: bag is normal saline Appropriate Label: name and dosage are correct Fluid Appearance: no visible abnormal appearance Assessed IV Pump Infusion Rate: IV pump is infusing IV fluid at the ordered rate Assessed IV Site Insertion Site: no visible abnormal signs Dressing: dry and intact Assessed Urine Quality Clarity of Urine: clear Color of Urine: pale yellow Odor: no noticeable odor Inspected Head and Face Skull Symmetry: symmetric Facial Feature Symmetry: symmetric Appearance: no visible abnormal findings Inspected Eyes Eyelids: no visible abnormal findings Conjunctiva and Lens: no visible abnormal findings Pupillary Reaction: no visible abnormal findings (PERRL) Accommodation: normal constriction and dilation Inspected Mouth Oral Mucosa and Gums: moist and pink, no bleeding Lips: smooth, pink, and moist Tongue: moist, pink Inspected Lower Legs Right: Appearance: no visible abnormal findings Left: Appearance: no visible abnormal findings Symmetry: symmetric bilaterally Inspected Skin Wounds or Sores: no abnormal findings Signs of Skin Trauma: scarring Color or Appearance: freckles, birthmarks, melasma, or other lesions Masses or Texture: no abnormal findings Skin Characteristics and Hair Growth: no abnormal findings Auscultated Carotids Right: no bruit Left: no bruit Auscultated Breath Sounds Breath Sounds: clear in all areas Adventitious Sounds: no adventitious sounds Auscultated Heart Sounds Heart Sounds: S1 and S2 audible Extra Heart Sounds: no extra sounds Rate and Rhythm: regular rate and rhythm Palpated Temporal Arteries Right: Observations: no abnormal findings Right: Amplitude: 2+ expected Left: Observations: no abnormal findings Left: Amplitude: 2+ expected Palpated PMI Location: present at midclavicular line and 5th intercostal space Size: <2 cm (penny or dime sized) Characteristics: brisk and tapping Palpated Posterior Tibial Pulse Right: Vibration: no thrill Right: Amplitude: 2+ expected Left: Vibration: no thrill Left: Amplitude: 2+ expected Palpated Dorsalis Pedis Pulse Right: Vibration: no thrill Right: Amplitude: 2+ expected Left: Vibration: no thrill Left: Amplitude: 2+ expected Tested Cognition Clock Drawing Test: missing or incorrectly placed numbers, or hands do not display requested time (0 points) Word Recall: correctly recalled one word (1 point) Tested Posture Observations: no difficulty standing erect, shoulders even; no reported pain; no swaying, falling, or widening of feet Tested Fine Motor Skills Observations at Rest: able to perform without difficulty; no tremor Observations with Held Posture: able to perform without difficulty; no tremor Observations with Movement: able to perform without difficulty; no tremor Tested Grip Strength Strength: 5 - active movement against full resistance without fatigue Tested Skin Turgor Observations: no tenting Tested Capillary Refill Capillary Refill Time: less than 2 seconds Tested Gait Initiation of Gait: no hesitancy Step Length: stepping foot passes stationary foot Step Height: steps clear floor Step Symmetry: right and left step length equal Step Continuity: steps are continuous Path: no deviation of path Trunk: no sway, no flexion, no use of arms, and no use of walking aid Walking Stance: heels set apart Time to Complete Test: less than or equal to 12 seconds (normal mobility)