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DENTIFYING SUBJECTIVE AND OBJECTIVE CUES FROM THE CASE STUDY SUBJECTIVE DATA OBJECTIVE DATA

DENTIFYING SUBJECTIVE AND OBJECTIVE CUES FROM THE CASE STUDY SUBJECTIVE DATA OBJECTIVE DATA

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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IDENTIFYING SUBJECTIVE AND OBJECTIVE CUES FROM THE CASE STUDY

SUBJECTIVE DATA

 OBJECTIVE DATA






 
the periphery. Both eyes are coordinated; moves in unison w/ parallel alignment (8 ocular movements). The client is unable to read font 12 of printout and have a vision of 20/100. Glaring into lights is one of her concern. Ears The auricles are brown in color, symmetrical and aligned w/ outer canthus of eye, about 10' from vertical view. Upon palpation, auricles are mobile, firm and not tender; pinna recoils after it is folded. Using an otoscope, distal 3rd contains thin hair follicles and glands; semi-transparent and pearly gray tympanic membrane. The client has difficulty in responding to normal voice and negative for watch tick test. Normal for Rinne's and Weber's test Nose She has symmetrical and straight nares, without discharge, flaring and uniform in color. Air moves freely through the nares as the client breathe. Nasal mucosa is pink and clear without any lesions. Nasal septum is intact and in midline. Nasal sinuses are non-tender. The client had difficulty in recognizing the smell of coffee. Mouth and Oropharynx Outer lips have uniform pink color, soft, dry, smooth in texture and able to purse lips. Inner lips and buccal mucosa is pink, moist, smooth, soft, glistening and elastic. She had 32 smooth and intact dentures, moist and firm. Absence of papillae is noted. Salivary glands are intact, pinkish in color w/o any lesions. Light pink hard and soft palate and are positioned in the midline w/o smooth posterior wall. Tonsils and uvula is not inflame0. Gag reflex is present. Neck Neck muscles are equal in size; head is at the center. Head movement is coordinated, smooth w/o discomfort. There is equal muscle strength and non-palpable lymph nodes. The trachea is in the midline. Thyroid gland is not palpable but ascends during swallowing. Breast and Axilla With brown, flat, symmetrical w/ fine glandular texture. There are no masses palpated. Nipples are pinkish color, dry and symmetrical. The axilla is brown in color, dry, w/o hair. Chest and Lungs The anteroposterior to transverse diameter is 2:1 ratio. She has a symmetrical chest expansion and a
Transcribed Image Text:the periphery. Both eyes are coordinated; moves in unison w/ parallel alignment (8 ocular movements). The client is unable to read font 12 of printout and have a vision of 20/100. Glaring into lights is one of her concern. Ears The auricles are brown in color, symmetrical and aligned w/ outer canthus of eye, about 10' from vertical view. Upon palpation, auricles are mobile, firm and not tender; pinna recoils after it is folded. Using an otoscope, distal 3rd contains thin hair follicles and glands; semi-transparent and pearly gray tympanic membrane. The client has difficulty in responding to normal voice and negative for watch tick test. Normal for Rinne's and Weber's test Nose She has symmetrical and straight nares, without discharge, flaring and uniform in color. Air moves freely through the nares as the client breathe. Nasal mucosa is pink and clear without any lesions. Nasal septum is intact and in midline. Nasal sinuses are non-tender. The client had difficulty in recognizing the smell of coffee. Mouth and Oropharynx Outer lips have uniform pink color, soft, dry, smooth in texture and able to purse lips. Inner lips and buccal mucosa is pink, moist, smooth, soft, glistening and elastic. She had 32 smooth and intact dentures, moist and firm. Absence of papillae is noted. Salivary glands are intact, pinkish in color w/o any lesions. Light pink hard and soft palate and are positioned in the midline w/o smooth posterior wall. Tonsils and uvula is not inflame0. Gag reflex is present. Neck Neck muscles are equal in size; head is at the center. Head movement is coordinated, smooth w/o discomfort. There is equal muscle strength and non-palpable lymph nodes. The trachea is in the midline. Thyroid gland is not palpable but ascends during swallowing. Breast and Axilla With brown, flat, symmetrical w/ fine glandular texture. There are no masses palpated. Nipples are pinkish color, dry and symmetrical. The axilla is brown in color, dry, w/o hair. Chest and Lungs The anteroposterior to transverse diameter is 2:1 ratio. She has a symmetrical chest expansion and a
Neck Neck muscles are equal in size; head is at the center. Head movement is coordinated, smooth w/o discomfort. There is equal muscle strength and non-palpable lymph nodes. The trachea is in the midline. Thyroid gland is not palpable but ascends during swallowing. Breast and Axilla With brown, flat, symmetrical w/ fine glandular texture. There are no masses palpated. Nipples are pinkish color, dry and symmetrical. The axilla is brown in color, dry, w/o hair. Chest and Lungs The anteroposterior to transverse diameter is 2:1 ratio. She has a symmetrical chest expansion and a kyphotic spine. Skin is intact, with uniform color and temperature. No tenderness and masses upon palpation. She has bilateral symmetry of vocal and tactile fremitus. Resonance is heard over the thorax. Diapragmatic excursion is 3cm. Costal angle is 80, and the ribs is 45. Upon auscultation, bronchial (trachea) sounds, bronchovesicular (main bronchi) sound and vesicular sounds (terminal bronchi) were heard. Нeart There are no masses and lesions in the skin. There is palpable pulsation at the left ICS (5th) MCL; in an area of 1-2 cm in diameter. The carotid pulse is bounding regularly synchronous with S1. The apical and radial pulse has equal rate and rhythm. Systolic murmur was heard during auscultation. Abdomen The color is uniform and the skin is unblemished. There are symmetric movements caused by respiration. Aortic pulsations were also noted at the epigastric' area. Bowel sounds is 3/min without arterial bruits and friction rub. Tympanic sounds were heard during auscultation. No tenderness, relaxed abdomen with smooth, consistent tension. The liver, bladder and spleen are not palpable. Upper and Lower Extremities Muscles are firm, smooth with coordinated movements and equal strength on both sides of the body. The client's fingers have swollen joints. Stiffness on the joints on the client's hands were noted. Patient claimed that the bones and joints on her hands, legs and feet are painful. Crepitations on the joints were also present.
Transcribed Image Text:Neck Neck muscles are equal in size; head is at the center. Head movement is coordinated, smooth w/o discomfort. There is equal muscle strength and non-palpable lymph nodes. The trachea is in the midline. Thyroid gland is not palpable but ascends during swallowing. Breast and Axilla With brown, flat, symmetrical w/ fine glandular texture. There are no masses palpated. Nipples are pinkish color, dry and symmetrical. The axilla is brown in color, dry, w/o hair. Chest and Lungs The anteroposterior to transverse diameter is 2:1 ratio. She has a symmetrical chest expansion and a kyphotic spine. Skin is intact, with uniform color and temperature. No tenderness and masses upon palpation. She has bilateral symmetry of vocal and tactile fremitus. Resonance is heard over the thorax. Diapragmatic excursion is 3cm. Costal angle is 80, and the ribs is 45. Upon auscultation, bronchial (trachea) sounds, bronchovesicular (main bronchi) sound and vesicular sounds (terminal bronchi) were heard. Нeart There are no masses and lesions in the skin. There is palpable pulsation at the left ICS (5th) MCL; in an area of 1-2 cm in diameter. The carotid pulse is bounding regularly synchronous with S1. The apical and radial pulse has equal rate and rhythm. Systolic murmur was heard during auscultation. Abdomen The color is uniform and the skin is unblemished. There are symmetric movements caused by respiration. Aortic pulsations were also noted at the epigastric' area. Bowel sounds is 3/min without arterial bruits and friction rub. Tympanic sounds were heard during auscultation. No tenderness, relaxed abdomen with smooth, consistent tension. The liver, bladder and spleen are not palpable. Upper and Lower Extremities Muscles are firm, smooth with coordinated movements and equal strength on both sides of the body. The client's fingers have swollen joints. Stiffness on the joints on the client's hands were noted. Patient claimed that the bones and joints on her hands, legs and feet are painful. Crepitations on the joints were also present.
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