N/A Objective Bowel sound normoactive all quadrants, no masses palpable, soft and non-tender, liver palpable 1cm below right costal margin, spleen not palpable, kidneys not palpable and no masses, absence of CVA tenderness, N/A Musculoskeletal Student Documentation Student Documentation Model D Model D Subjective No complaints of weakness, pain, or difficulty walking, or picking up, or bending/twisting. N/A
1/29/2020 Blackboard Learn ; 6/7 Student Documentation Student Documentation Model D Model D Objective All extremities,neck, shoulder, hip, back 5/5 strength, ROM WNL for all extremites, neck, all areas adduction, abduction, inversion, eversion, extension, flexion, bending, supination, pronation, normal, spine midline, N/A Neurological Student Documentation Student Documentation Model D Model D Subjective Patient denies dizzyness, headaches, numbness/tingling, sharp/dull sensation normal throughout. N/A Objective Heel moving to shin intact, able to touch ringer to nose without difficulty, alert and oriented times 4, memory intact, gross and fine motor movement intact, sharp/dull/soft sensation intact throughout, some sensation loss to left foot near pad/toes, all reflexes 2+, sterognosis and graphesthesia are intact. N/A Skin, Hair & Nails Student Documentation Model D Subjective Patient has no complaints of rashes, itching, dry skin, wounds, scars. N/A
1/29/2020 Blackboard Learn ; 7/7 Student Documentation Student Documentation Model D Model D Objective No obvious wounds, scars, rashes, discoloration, skin warm.dry, normal for race, nails have no ridges or abnormalities, hair is thick, full, no issues. N/A
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- Fall '17
- Tina denis