Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection

Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection

Objective Data Collection: 21 of 21 (100%)

Assessed Vitals
1 of 1 point
Temperature (1/5 point)

– Normothermic
– Hyperthermic
– Hypothermic

Blood Pressure (1/5 point)

– Normotensive
– Hypertensive
– Hypotensive

Heart Rate (1/5 point)

– Normal
– Tachycardic
– Bradycardic

Respiratory Rate (1/5 point)

– Normal
– Tachypnea
– Bradypnea

O2 Saturation (1/5 point)

– Normal
– Hypoxemia

Inspected Eyes
1 of 1 point
Pupillary Reaction (1/2 point)

– Normal
– Unequal
– Irregular
– Miosis
– Mydriasis
– Non-reactive to light

Accommodation (1/2 point)

– Normal constriction and dilation
– Unequal or no pupillary constriction
– Unequal or no pupillary dilation

Inspected Injury
1 of 1 point
Left Hand (1/4 point)

– Normal
– Swelling
– Redness
– Bruising
– Rash

Left Wrist (1/4 point)

– Normal
– Swelling
– Redness
– Bruising
– Rash

Right Hand (1/4 point)

– Normal
– Swelling
– Redness
– Bruising
– Rash

Right Wrist (1/4 point)

– Normal
– Swelling
– Redness
– Bruising
– Rash

Inspected Upper Extremities for Self-harm or Abuse
1 of 1 point
Observations (1/3 point)

– No visible evidence of self-harm or abuse
– Evidence of self-harm
– Evidence of abuse

Wounds Or Scars (1/3 point)

– No visible wounds or scars
– Wound visible
– Scar visible

Location Of Visible Abnormality (1/3 point)

– No visible abnormality
– Right upper arm
– Right lower arm
– Right wrist
– Right hand
– Left upper arm
– Left lower arm
– Left wrist
– Left hand

Auscultated Breath Sounds
1 of 1 point
Breath Sounds (1/2 point)

– Clear in all areas
– Diminished in some areas
– Absent in some areas

Adventitious Sounds (1/2 point)

– No adventitious sounds
– Wheezing
– Fine crackles
– Stridor
– Rhonchi
– Rales

Auscultated Heart Sounds
1 of 1 point
Heart Sounds (1/3 point)

– S1 and S2 audible
– S1, S2, and S3 audible
– S1, S2, and S4 audible
– S1, S2, S3, and S4 audible

Extra Heart Sounds (1/3 point)

– No extra sounds
– Gallops
– Murmur
– Friction rub
– Valve clicks

Rate And Rhythm (1/3 point)

– Regular rate and rhythm
– Arrhythmia

Palpated Radial Arteries
1 of 1 point
Right: Vibration (1/4 point)

– No thrill
– Thrill

Right: Amplitude (1/4 point)

– 0 Absent
– 1+ Diminished or barely palpable
– 2+ Expected
– 3+ Increased
– 4+ Bounding pulse

Left: Vibration (1/4 point)

– No thrill
– Thrill

Left: Amplitude (1/4 point)

– 0 Absent
– 1+ Diminished or barely palpable
– 2+ Expected
– 3+ Increased
– 4+ Bounding pulse

Tested Capillary Refill
1 of 1 point
Right Hand (1/2 point)

– Less than 2 seconds
– Greater than 2 seconds

Left Hand (1/2 point)

– Less than 2 seconds
– Greater than 2 seconds

Assessed General Appearance
1 of 1 point
Eye Contact (1/4 point)

– Direct eye contact
– Indirect or no eye contact

Posture (1/4 point)

– Upright posture without tension or rigidity
– Bent or hunched posture, tension, or rigidity

Clothing (1/4 point)

– Clean clothing, appropriate to age, fit, season, and occasion
– Dirty, disheveled, or inappropriate to age, fit, season, or occasion

Grooming (1/4 point)

– Demonstrates an appropriate level of grooming
– Signs indicating lack of grooming or self-care

Assessed Attitude Toward Medical Staff
1 of 1 point
Attitude Toward Medical Staff (1/1 point)

– Generally open and cooperative
– Generally suspicious, guarded, or evasive

Assessed Speech
1 of 1 point
Rate (1/3 point)

– Demonstrates appropriate or expected rate of speech
– Excessively slow or rapid rate of speech

Volume (1/3 point)

– Demonstrates appropriate or expected speech volume
– Excessively loud or soft speech volume

Articulation (1/3 point)

– No appreciable issues with articulation
– Issues with articulation, slurring, or stutters

Assessed Mood and Affect
1 of 1 point
Mood (1/2 point)

– Stable mood with little or no fluctuation throughout the interview
– Frequent and appreciable mood changes throughout the interview

Affect (1/2 point)

– Full or balanced (normal)
– Expansive affect (excessively cheerful affect characterized by contagious laughter or smiling)
– Blunted or flat affect (little to no variation of expression regardless of conversation topic)

Assessed Thought Process
1 of 1 point
Thought Process (1/1 point)

– No presence of thought process disturbances
– Presence of rapid thinking, disorganized or illogical flow of thought, “word salad,” neologisms, echolalia, or clanging associations

Assessed Thought Content
1 of 1 point
Thought Content (1/2 point)

– No presence of thought content disturbances
– Presence of delusions, obsessive or intrusive thoughts, or suicidal or homicidal ideation

Perceptual Disturbances (1/2 point)

– No presence of perceptual disturbances
– Presence of auditory or visual hallucinations

Confirmed Orientation
1 of 1 point
To Person (1/4 point)

– Oriented to person
– Not oriented to person

To Place (1/4 point)

– Oriented to place
– Not oriented to place

To Time (1/4 point)

– Oriented to time
– Not oriented to time

To Situation (1/4 point)

– Oriented to situation
– Not oriented to situation

Assessed Serial Sevens
1 of 1 point
Serial Sevens (1/1 point)

– Able to complete the series
– Unable to complete the series

Assessed Abstract Thinking
1 of 1 point
Abstract Thinking (1/1 point)

– Demonstrates abstract thinking with similarities test
– Demonstr

ates concrete thinking with similarities test

Assessed Memory
1 of 1 point
Memory (1/1 point)

– Remote and immediate memory intact
– Remote or immediate memory not intact

Assessed Visuospatial Ability
1 of 1 point
Visuospatial Ability (1/1 point)

– Visuospatial ability intact for interlocking shapes test
– Visuospatial ability impaired with interlocking shapes test

Assessed Insight
1 of 1 point
Insight (1/1 point)

– Demonstrates full awareness of illness and willingness to seek treatment
– Demonstrates limited or no awareness of illness and/or is unwilling to seek treatment

Assessed Judgment
1 of 1 point
Judgment (1/1 point)

– Demonstrates good judgment
– Judgment poor or impaired judgment