•  Normothermic
•  Hyperthermic
•  Hypothermic

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•  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

•  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

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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