Well Visit: New Patient: Xavier Daniels (complete)

Well Visit: New Patient Results | Turned In
Advanced Nursing Practice I - Primary Care - Adult - January 2024, 202410nur6121803

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Your Results Lab Pass (/assignment_attempts/16316086/lab_pass.pd




Overview
Objective Data Collection: 16 of 16 (100%)
Transcript

Subjective Data Collection Correct Incorrect
Partially correct Missed
Objective Data Collection

Education & Empathy
Inspected Head 1 of 1 point
Documentation

Treatment Plan Skull Symmetry (1/3 point) Facial Feature Symmetry (1/3 point)
Symmetric Symmetric
Reflection
Asymmetric Asymmetric
Student Survey
Appearance (1/3 point)
No visible abnormal findings
Flushed appearance
Rash or lesion
Skin growth (freckles, moles, or birthmark)
Excessive hair growth
Evidence of skin trauma (scar, laceration, or bruising)



Inspected Fundus 1 of 1 point



Right: Fundus (1/4 point) Right: Disc Margin (1/4 point)
No visible abnormal findings Sharp
Arteriovenous nicking Blurred
Myelinated nerve fibers
Papilledema
Glaucomatous cupping
Drusen bodies
Cotton wool bodies
Hemorrhage

Left: Fundus (1/4 point) Left: Disc Margin (1/4 point)
No visible abnormal findings Sharp
Arteriovenous nicking Blurred

, Myelinated nerve fibers
Papilledema
Glaucomatous cupping
Drusen bodies
Cotton wool bodies
Hemorrhage


Inspected Ears

Left Auditory Canal Color (1/6 point) Left Tympanic Membrane Appearance (1/6
Pink No visible abnormal findings
Red Fluid observed
Pallor Visible scars
Bulging
Perforation
Retraction

Left Ear Discharge (1/6 point) Right Auditory Canal Color (1/6 point)
No discharge Pink
Cerumen Red
Clear discharge Pallor
Bloody discharge
Purulent discharge

Right Tympanic Membrane Appearance (1/6 point) Right Ear Discharge (1/6 point)
No visible abnormal findings No discharge
Fluid observed Cerumen
Visible scars Clear discharge
Bulging Bloody discharge
Perforation Purulent discharge
Retraction



Inspected Nose

Color (1/4 point) Discharge (1/4 point)
Pink No discharge
Pale Clear discharge
Erythemic Bloody discharge
Bluish Purulent discharge

Turbinate Patency (1/4 point) Observations (1/4 point)
Patent No additional visible abnormal findings
Decreased patency Foreign body present
Not patent Polyp
Septum perforated
Septum deviated
Lesion



Inspected Throat

Oral Mucosa (1/3 point) Tonsils (1/3 point)
Moist and pink No visible abnormal findings
Dry appearance Edema
Erythemic Erythema

, Posterior Oropharynx Color (1/3 point)
Pink
Erythemic



Auscultated Abdominal Arteries

Auscultated Heart Sounds

Heart Sounds (1/2 point) Extra Heart Sounds (1/2 point)
S1 and S2 audible No extra sounds
S1, S2, and S3 audible Gallops
S1, S2, and S4 audible Murmur
S1, S2, S3, and S4 audible Friction rub
Valve clicks



Auscultated Carotids

Right (1/2 point) Left (1/2 point)
No bruit No bruit
Bruit Bruit



Palpated Abdomen, Light

Tenderness (1/2 point) Observations (1/2 point)
No tenderness reported No additional observations
Reported in right upper quadrant Masses
Reported in right lower quadrant Guarding
Reported in left upper quadrant Distension
Reported in left lower quadrant Pulsations



Palpated Carotids

Right: Vibration (1/4 point) Right: Amplitude (1/4 point)
No thrill 0: Absent
Thrill 1+: Diminished or barely palpable
2+: Expected
3+: Increased
4+: Bounding pulse

Left: Vibration (1/4 point) Left: Amplitude (1/4 point)
No thrill 0: Absent
Thrill 1+: Diminished or barely palpable
2+: Expected
3+: Increased
4+: Bounding pulse



Palpated Peripheral Pulses

Radial Artery Amplitude (1/4 point) Brachial Artery Amplitude (1/4 point)
0: Absent 0: Absent
1+: Diminished or barely palpable 1+: Diminished or barely palpable