Lucas Callahan Bipolar Disorder Objective Data Collection
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
Objective Data Collection: 27.67 of 28 (98.82%)
- Correct
- Partially correct
- Incorrect
- Missed
- Normothermic
- Hyperthermic
- Hypothermic
- Normotensive
- Hypertensive
- Hypotensive
- Normal
- Tachycardic
- Bradycardic
- Normal
- Tachypnea
- Bradypnea
- Normal
- Hypoxemia
- No visible abnormal findings
- Redness
- Bruising or other discoloration
- Edema
- Visible mass
- Atrophy
- Hypertrophy
- No visible abnormal findings
- Redness
- Bruising or other discoloration
- Edema
- Visible mass
- Atrophy
- Hypertrophy
- Symmetric bilaterally
- Asymmetric
- Pink
- Red
- Bluish
- No discharge
- Clear discharge
- Bloody discharge
- Purulent discharge
- No additional visible abnormal findings
- Foreign body present
- Polyp
- Septum perforated
- Septum deviated
- Lesion
-
BUY A PLAGIARISM-FREE ESSAY HERE
- No visible abnormal findings
- Rash
- Moles or skin tags
- Freckles, birthmark, or other discoloration
- Excessive dry or flaking skin
- Purpura
- Striae
- Scratching
- Bruising
- Normal
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
- Normal constriction and dilation
- Unequal or no pupillary constriction
- Unequal or no pupillary dilation
- White
- Yellow Tint
- Redness
- Symmetric
- Asymmetric
- 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
- No visible evidence of self-harm or abuse
- Evidence of self-harm
- No visible wounds or scars
- Wound visible
- Scar visible
- No visible abnormality
- Right upper arm
- Right lower arm
- Right wrist
- Right hand
- Left upper arm
- Left lower arm
- Left wrist
- Left hand
- Clear in all areas
- Diminished in some areas
- Absent in some areas
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
- S1 and S2 audible
- S1, S2, and S3 audible
- S1, S2, and S4 audible
- S1, S2, S3, and S4 audible
- No extra sounds
- Gallops
- Murmur
- Friction rub
- Valve clicks
- Regular rate and rhythm
- Irregular rate
- Arrhythmia
- Less than 2 seconds
- Greater than 2 seconds
- Less than 2 seconds
- Greater than 2 seconds
- No Thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No Thrill
- Thrills
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No Thrill
- Thrills
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No Thrill
- Thrills
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- None Reported
- Tenderness Reported
- No quadrants tender
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
- No additional observations
- Masses
- Guarding
- Distension
- No palpable mass
- Palpable mass
- No palpable mass
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
- Around umbilicus
- Regular
- Irregular
- No ST elevation
- ST elevation present
- Positive for substances
- Negative for substances
- Both levels within normal ranges
- Thyroxine-binding globulin elevated
- Thyroxine-binding globulin low
- Thyroid-stimulating hormone (TSH) elevated
- Thyroid-stimulating hormone (TSH) low
- Direct eye contact
- Indirect or no eye contact
- Upright posture without tension or rigidity
- Bent or hunched posture, tension, or rigidity
- Clean clothing, appropriate to age, fit, season, and occasion
- Dirty, disheveled, or inappropriate to age, fit, season, or occasion
- Demonstrates an appropriate level of grooming
- Signs indicating lack of grooming or self-care
- Generally open and cooperative
- Generally suspicious, guarded, or evasive
- Demonstrates appropriate or expected rate of speech
- Excessively slow or rapid rate of speech
- Demonstrates appropriate or expected speech volume
- Excessively loud or soft speech volume
- No appreciable issues with articulation
- Issues with articulation, slurring, or stutters
- Stable mood with little or no fluctuation throughout the interview
- Frequent and appreciable mood changes throughout the interview
- 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)
- No presence of thought process disturbances
- Presence of rapid thinking, disorganized or illogical flow of thought, “word salad,” neologisms, echolalia, or clanging associations
- No presence of thought content disturbances
- Presence of delusions, obsessive or intrusive thoughts, or suicidal or homicidal ideation
- No presence of perceptual disturbances
- Presence of auditory or visual hallucinations
- Oriented to person
- Not oriented to person
- Oriented to place
- Not oriented to place
- Oriented to time
- Not oriented to time
- Oriented to situation
- Not oriented to situation
- Able to complete the series
- Unable to complete the series
- Demonstrates abstract thinking with similarities test
- Demonstrates concrete thinking with similarities test
- Remote and immediate memory intact
- Remote or immediate memory not intact
- Visuospatial ability intact for interlocking shapes test
- Visuospatial ability impaired with interlocking shapes test
- Demonstrates full awareness of illness and willingness to seek treatment
- Demonstrates limited or no awareness of illness and/or is unwilling to seek treatment
- Demonstrates good judgment
- Judgment poor or impaired judgment
