Shadow Health - Edward Carter - Pain - Objective

Temperature: normothermic Blood Pressure: normotensive Heart Rate: no abnormal findings Respiratory Rate: no abnormal findings O2 Saturation: no abnormal findings

Appropriate Fluid: bag is normal saline Appropriate Label: name and dosage are correct Fluid Appearance: no visible abnormal appearance

Observations: IV pump is infusing IV fluids at the ordered rate

Insertion Site: no visible abnormal signs Dressing: dry and intact

Skull Symmetry: symmetric Facial Feature Symmetry: symmetric Appearance: no visible abnormal findings

Eyelids: no visible abnormal findings Conjunctiva and Lens: no visible abnormal findings Pupillary Reaction: no visible abnormal findings (PERRL)

Oral Mucosa and Gums: Moist and pink, no bleeding Lips: smooth, pink, and moist Tongue: moist, pink

Appearance: edema

Right: Appearance: no visible abnormal findings Left: Appearance: no visible abnormal findings Symmetry: symmetric bilaterally

Alignment: Valgus deformity Left Knee: Appearance: visible swelling Right Knee: Appearance: visible swelling

Right: Appearance: no visible abnormal findings Left: Appearance: no visible abnormal findings Symmetry: symmetric bilaterally

Wounds or Sores: no abnormal findings Signs of Skin Trauma: no abnormal findings Color or Appearance: redness Masses or Texture: no abnormal findings Skin Characteristics and Hair Growth: no abnormal findings

Right: no bruit Left: no bruit

Breath Sounds: clear in all areas Adventitious Sounds: no adventitious sounds

Heart Sounds: S1 and S2 audible Extra Heart Sounds: no extra sounds Rate and Rhythm: regular rate and rhythm

Location: present at midclavicular line and 5th intercostal space Size: <2 cm (penny or dime sized) Characteristics: brisk and tapping

Right: -reported tenderness -effusion -bony swelling -crepitus, popping or clicking Left: -reported tenderness -effusion -bony swelling -crepitus, popping or clicking

Right: Vibration: no thrill Right: Amplitude: 2+ expected Left: Vibration: no thrill Left: Amplitude: 2+ expected

Right: Vibration: no thrill Right: Amplitude: 2+ expected Left: Vibration: no thrill Left: Amplitude: 2+ expected

Observations at Rest (Arms and Hands at Patient's Sides): able to perform without difficulty; no tremor Observations with Held Posture (Forward Extension of Patient's Arms): able to perform without difficulty; no tremor Observations with Movement (Nose to Finger Test): able to perform without difficulty; no tremor

Clock Drawing Test: all numbers present in correct sequence and position; hands display requested time (2 points) Word Recall: correctly recalled 3 words (3 points)

Strength: 3 - active movement against gravity

Right: 3 - active movement against gravity Left: 3 - active movement against gravity

Flexion: reduced hip flexion Extension: reduced hip extension Abduction: reduced hip abduction Adduction: reduced hip adduction

Right: Flexion: reduced flexion Right: Extension: reduced extension Left: Flexion: reduced flexion Left: Extension: reduced extension

Observations: no tenting

Capillary Refill Time: less than 2 seconds

Initiation of Gait: hesitancy or multiple attempts to start Step Length: stepping foot passes stationary foot Step Height: step clears floor Step Symmetry: right and left step length equal Step continuity: steps are continuous Path: some path deviation or use of walking aid Trunk: observable sway or use of walking aid Walking Stance: heels set apart Time to Complete Test: greater than 12 seconds (increased likelihood of falls)