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