Lucas Callahan Bipolar Disorder Objective Data Collection

Uncategorized

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