NR 509 Shadow Health Comprehensive Assessment Instructor's Guide

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Category Scored Items Experts selected these examinations as essential components of objective data collection for this patient. Patient Data Not Scored Thorough examinations will yield better p... atient 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 Objective Data Collection: 71.0 of 73 (97.3%) Overview Transcript Subjective Data Collection Objective Data Collection Documentation Plan My Exam Self-Reflection Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips. 6/12/2018 Comprehensive Assessment | Completed | Shadow Health https://chamberlain.shadowhealth.com/assignment_attempts/3569767 2/10 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 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 [Show More]

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