Shadow Health Assignments
Lucas Callahan Bipolar Disorder Objective Data Collection
Objective Data Collection: 27.67 of 28 (98.82%)
Assessed Vitals
1 of 1 point
Temperature (1/5 point)
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Normal body temperature
Body temperature higher than normal
Body temperature lower than normal
Blood Pressure (1/5 point)
Normal blood pressure
High blood pressure
Low blood pressure
Heart Rate (1/5 point)
Regular heart rate
Fast heart rate
Slow heart rate
Respiratory Rate (1/5 point)
Normal respiratory rate
Fast breathing
Slow breathing
O2 Saturation (1/5 point)
Normal oxygen saturation
Low oxygen levels
Inspected Legs
1 of 1 point
Right: Appearance (1/3 point)
No abnormal findings visible
Redness
Bruises or other discoloration
Swelling
Visible mass
Atrophy
Muscle overgrowth
Left: Appearance (1/3 point)
No abnormal findings visible
Redness
Bruises or other discoloration
Swelling
Visible mass
Atrophy
Muscle overgrowth
Symmetry (1/3 point)
Symmetrical on both sides
Asymmetrical
Inspected Nose
1 of 1 point
Color (1/3 point)
Pink
Red
Bluish
Discharge (1/3 point)
No discharge
Clear discharge
Bloody discharge
Pus-like discharge
Observations (1/3 point)
No additional visible abnormalities
Foreign object present
Polyp
Perforated septum
Deviated septum
Lesion
Inspected Back
1 of 1 point
Appearance (1/1 point)
No visible abnormalities
Rash
Moles or skin tags
Freckles, birthmark, or other discoloration
Excessively dry or flaky skin
Purpura (purple spots)
Stretch marks
Scratching marks
Bruises
Inspected Eyes
1 of 1 point
Pupillary Reaction (1/3 point)
Normal reaction
Unequal pupils
Irregular pupils
Constricted pupils
Dilated pupils
No reaction to light
Reaction (1/3 point)
Normal constriction and dilation
Unequal constriction or no constriction
Unequal dilation or no dilation
Sclera (1/3 point)
White
Yellow tint
Redness
Inspected Chest
1 of 1 point
Symmetry (1/2 point)
Symmetrical
Asymmetrical
Appearance (1/2 point)
No visible abnormalities
Redness
Rash
Moles or skin tags
Masses (warts, cysts, or tumors)
Freckles, birthmark, or other discoloration
Excessively dry or flaky skin
Purpura (purple spots)
Stretch marks
Bruises
Scarring
Inspected Arms
0.67 of 1 point
Observations (1/3 point)
No visible signs of self-harm or abuse
Evidence of self-harm
Wounds Or Scars (1/3 point)
No visible wounds or scars
Visible wound
Visible scar
Location Of Visible Abnormality (No 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 sounds in all areas
Diminished sounds in some areas
Absent sounds in some areas
Adventitious Sounds (1/2 point)
No unusual sounds
Wheezing
Fine crackles
Stridor
Rhonchi
Rales
Auscultated Heart Sounds
1 of 1 point
Heart Sounds (1/3 point)
Audible S1 and S2
Audible S1, S2, and S3
Audible S1, S2, and S4
Audible S1, S2, S3, and S4
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
Irregular rate
Arrhythmia
Palpated Capillary Refill
1 of 1 point
Right Hand (1/2 point)
Less than 2 seconds
More than 2 seconds
Left Hand (1/2 point)
Less than 2 seconds
More than 2 seconds
Palpated Radial Arteries
1 of 1 point
Right: Vibration (1/4 point)
No vibration
Vibration felt
Right: Amplitude (1/4 point)
0 Absent
1+ Diminished or barely felt
2+ Normal
3+ Increased
4+ Strong pulse
Left: Vibration (1/4 point)
No vibration
Vibration felt
Left: Amplitude (1/4 point)
0 Absent
1+ Diminished or barely felt
2+ Normal
3+ Increased
4+ Strong pulse
Palpated Dorsalis Pedis Arteries
1 of 1 point
Right: Vibration (1/4 point)
No vibration
Vibration felt
Right: Amplitude (1/4 point)
0 Absent
1+ Diminished or barely felt
2+ Normal
3+ Increased
4+ Strong pulse
Left: Vibration (1/4 point)
No vibration
Vibration felt
Left: Amplitude (1/4 point)
0 Absent
1+ Diminished or barely felt
2+ Normal
3+ Increased
4+ Strong pulse
Palpated Abdomen
1 of 1 point
Tenderness (1/5 point)
No reported tenderness
Reported tenderness
Location Of Tenderness (1/5 point)
No quadrant tender
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Observations (1/5 point)
No additional observations
Masses
Guarding
Distension
Presence Of Unexpected Mass (1/5 point)
No palpable mass
Palpable mass
Location Of Mass (1/5 point)
No palpable mass
Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Around umbilicus
Performed EKG
1 of 1 point
Sinus Rhythm (1/2 point)
Regular
Irregular
ST Changes (1/2 point)
No ST elevation
ST elevation present
Assessed Labs
1 of
1 point
Drug Screen Results (1/2 point)
Tested positive for substances
Tested negative for substances
Thyroid Function Tests (1/2 point)
Both levels within normal ranges
Elevated thyroxine-binding globulin
Low thyroxine-binding globulin
Elevated thyroid-stimulating hormone (TSH)
Low thyroid-stimulating hormone (TSH)
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, suitable for age, fit, season, and occasion
Dirty, unkempt, or unsuitable for age, fit, season, or occasion
Grooming (1/4 point)
Shows appropriate level of grooming
Signs of inadequate 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 speech rate
Speech rate excessively slow or rapid
Volume (1/3 point)
Demonstrates appropriate or expected speech volume
Speech volume excessively loud or soft
Articulation (1/3 point)
No noticeable issues with articulation
Issues with articulation, slurring, or stuttering
Assessed Mood and Affect
1 of 1 point
Mood (1/2 point)
Stable mood with minimal fluctuation during interview
Frequent and noticeable mood changes during interview
Affect (1/2 point)
Full or balanced (normal) affect
Excessively cheerful affect (expansive affect)
Flat or blunted affect (little variation in expression regardless of topic)
Assessed Thought Process
1 of 1 point
Thought Process (1/1 point)
No signs of thought process disturbances
Rapid thinking, disorganized or illogical thought flow, “word salad,” neologisms, echolalia, or clanging associations present
Assessed Thought Content
1 of 1 point
Thought Content (1/2 point)
No signs of thought content disturbances
Delusions, obsessive or intrusive thoughts, or thoughts of suicide or harm present
Perceptual Disturbances (1/2 point)
No signs of perceptual disturbances
Auditory or visual hallucinations present
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
Demonstrates 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)
Intact visuospatial ability for interlocking shapes test
Impaired visuospatial ability with interlocking shapes test
Assessed Insight
1 of 1 point
Insight (1/1 point)
Fully aware of illness and willing to seek treatment
Limited or no awareness of illness and/or unwilling to seek treatment
Assessed Judgment
1 of 1 point
Judgment (1/1 point)
Displays good judgment
Judgment is poor or impaired
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Objective Data Collection: 27.67 of 28 (98.82%)
- Correct
- Partially correct
- Incorrect
- Missed
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 Legs
1 of 1 point
Right: Appearance (1/3 point)
- No visible abnormal findings
- Redness
- Bruising or other discoloration
- Edema
- Visible mass
- Atrophy
- Hypertrophy
Left: Appearance (1/3 point)
- No visible abnormal findings
- Redness
- Bruising or other discoloration
- Edema
- Visible mass
- Atrophy
- Hypertrophy
Symmetry (1/3 point)
- Symmetric bilaterally
- Asymmetric
Inspected Nose
1 of 1 point
Color (1/3 point)
- Pink
- Red
- Bluish
Discharge (1/3 point)
- No discharge
- Clear discharge
- Bloody discharge
- Purulent discharge
Observations (1/3 point)
- No additional visible abnormal findings
- Foreign body present
- Polyp
- Septum perforated
- Septum deviated
- Lesion
Inspected Back
1 of 1 point
Appearance (1/1 point)
- No visible abnormal findings
- Rash
- Moles or skin tags
- Freckles, birthmark, or other discoloration
- Excessive dry or flaking skin
- Purpura
- Striae
- Scratching
- Bruising
Inspected Eyes
1 of 1 point
Pupillary Reaction (1/3 point)
- Normal
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
Reaction (1/3 point)
- Normal constriction and dilation
- Unequal or no pupillary constriction
- Unequal or no pupillary dilation
Sclera (1/3 point)
- White
- Yellow Tint
- Redness
Inspected Chest
1 of 1 point
Symmetry (1/2 point)
- Symmetric
- Asymmetric
Appearance (1/2 point)
- No visible abnormal findings
- Redness
- Rash
- Moles or skin tags
- Masses (warts, cysts, or tumors)
- Freckles, birthmark, or other discoloration
- Excessive dry or flaking skin
- Purpura
- Striae
- Bruising
- Scarring
Inspected Arms
0.67 of 1 point
Observations (1/3 point)
- No visible evidence of self-harm or abuse
- Evidence of self-harm
Wounds Or Scars (1/3 point)
- No visible wounds or scars
- Wound visible
- Scar visible
Location Of Visible Abnormality (No 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
- Irregular rate
- Arrhythmia
Palpated 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
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
- Thrills
Left: Amplitude (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Palpated Dorsalis Pedis Arteries
1 of 1 point
Right: Vibration (1/4 point)
- No Thrill
- Thrills
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
- Thrills
Left: Amplitude (1/4 point)
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
Palpated Abdomen
1 of 1 point
Tenderness (1/5 point)
- None Reported
- Tenderness Reported
Location Of Tenderness (1/5 point)
- No quadrants tender
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
Observations (1/5 point)
- No additional observations
- Masses
- Guarding
- Distension
Presence Of Unexpected Mass (1/5 point)
- No palpable mass
- Palpable mass
Location Of Mass (1/5 point)
- No palpable mass
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
- Around umbilicus
Performed EKG
1 of 1 point
Sinus Rhythm (1/2 point)
- Regular
- Irregular
St Changes (1/2 point)
- No ST elevation
- ST elevation present
Assessed Labs
1 of 1 point
Drug Screen Results (1/2 point)
- Positive for substances
- Negative for substances
Thyroid Function Tests (1/2 point)
- Both levels within normal ranges
- Thyroxine-binding globulin elevated
- Thyroxine-binding globulin low
- Thyroid-stimulating hormone (TSH) elevated
- Thyroid-stimulating hormone (TSH) low
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
- Demonstrates 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