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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
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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
Lucas Callahan Bipolar Disorder Objective Data Collection
Objective Data Collection: 27.67 out of 28 (98.82%)
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Assessed Vitals
Temperature
– Normal body temperature
Blood Pressure
– Normal blood pressure
Heart Rate
– Normal heart rate
Respiratory Rate
– Normal respiratory rate
O2 Saturation
– Normal oxygen saturation
Inspected Legs
Right Leg:
– No visible abnormal findings
– No redness
– No bruising or other discoloration
– No edema
– No visible mass
– No atrophy
– No hypertrophy
Left Leg:
– No visible abnormal findings
– No redness
– No bruising or other discoloration
– No edema
– No visible mass
– No atrophy
– No hypertrophy
Symmetry
– Legs are symmetric bilaterally
Inspected Nose
Nose Color
– Pink
Nose Discharge
– No discharge
Nose Observations
– No additional visible abnormal findings
Inspected Back
Back Appearance
– No visible abnormal findings
Inspected Eyes
Pupillary Reaction
– Pupils react normally to light
Pupil Reaction
– Normal constriction and dilation
Sclera
– White sclera
Inspected Chest
Chest Symmetry
– Chest is symmetric
Chest Appearance
– No visible abnormal findings
Inspected Arms
Arm Observations
– No visible evidence of self-harm or abuse
Arm Wounds Or Scars
– No visible wounds or scars
Auscultated Breath Sounds
Breath Sounds
– Clear in all areas
Auscultated Heart Sounds
Heart Sounds
– S1 and S2 audible
Extra Heart Sounds
– No extra sounds
Heart Rate and Rhythm
– Regular rate and rhythm
Palpated Capillary Refill
Right Hand Capillary Refill
– Less than 2 seconds
Left Hand Capillary Refill
– Less than 2 seconds
Palpated Radial Arteries
Right Arm Vibration
– No thrill
Right Arm Amplitude
– Expected amplitude
Left Arm Vibration
– No thrill
Left Arm Amplitude
– Expected amplitude
Palpated Dorsalis Pedis Arteries
Right Foot Vibration
– No thrill
Right Foot Amplitude
– Expected amplitude
Left Foot Vibration
– No thrill
Left Foot Amplitude
– Expected amplitude
Palpated Abdomen
Abdomen Tenderness
– No reported tenderness
Tenderness Location
– No quadrants tender
Abdomen Observations
– No additional observations
Presence Of Unexpected Mass
– No palpable mass
Location Of Mass
– No palpable mass
Performed EKG
EKG Sinus Rhythm
– Regular
EKG St Changes
– No ST elevation
Assessed Labs
Drug Screen Results
– Negative for substances
Thyroid Function Tests
– Both levels within normal ranges
Assessed General Appearance
Eye Contact
– Direct eye contact
Posture
– Upright posture without tension or rigidity
Clothing
– Clean clothing, appropriate to age, fit, season, and occasion
Grooming
– Demonstrates an appropriate level of grooming
Assessed Attitude Toward Medical Staff
– Generally open and cooperative
Assessed Speech
Speech Rate
– Demonstrates appropriate or expected rate of speech
Speech Volume
– Demonstrates appropriate or expected speech volume
Speech Articulation
– No appreciable issues with articulation
Assessed Mood and Affect
Mood
– Stable mood with little or no fluctuation throughout the interview
Affect
– Full or balanced (normal) affect
Assessed Thought Process
– No presence of thought process disturbances
Assessed Thought Content
Thought Content
– No presence of thought content disturbances
Perceptual Disturbances
– No presence of perceptual disturbances
Confirmed Orientation
Orientation To Person
– Oriented to person
Orientation To Place
– Oriented to place
Orientation To Time
– Oriented to time
Orientation To Situation
– Oriented to situation
Assessed Serial Sevens
– Able to complete the series
Assessed Abstract Thinking
– Demonstrates abstract thinking with similarities test
Assessed Memory
– Remote and immediate memory intact
Assessed Visuospatial Ability
– Visuospatial ability intact for interlocking shapes test
Assessed Insight
– Demonstrates full awareness of illness and willingness to seek treatment
Assessed Judgment
– Demonstrates good judgment
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