Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection

•  Normothermic
•  Hyperthermic
•  Hypothermic

•  Normotensive
•  Hypertensive
•  Hypotensive

•  Normal
•  Tachycardic
•  Bradycardic

Comprehensive Assessment, Tina Jones shadow health Transcript

•  Normal
•  Tachypnea
•  Bradypnea

•  Normal
•  Hypoxemia
• Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection

•  Normal
•  Unequal
•  Irregular
•  Miosis
•  Mydriasis
•  Non-reactive to light

•  Normal constriction and dilation
•  Unequal or no pupillary constriction
•  Unequal or no pupillary dilation

•  Normal
•  Swelling
•  Redness
•  Bruising
•  Rash

•  Normal
•  Swelling
•  Redness
•  Bruising
•  Rash

•  Normal
•  Swelling
•  Redness
•  Bruising
•  Rash

•  Normal
•  Swelling
•  Redness
•  Bruising
•  Rash

•  No visible evidence of self-harm or abuse
•  Evidence of self-harm
•  Evidence of abuse

•  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
•  Arrhythmia

•  No thrill
•  Thrill

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

•  No thrill
•  Thrill

•  0 Absent
•  1+ Diminished or barely palpable
•  2+ Expected
•  3+ Increased
•  4+ Bounding pulse

•  Less than 2 seconds
•  Greater than 2 seconds

•  Less than 2 seconds
•  Greater than 2 seconds

•  Direct eye contact
•  Indirect or no eye contact

•  Upright posture without tension or rigidity
•  Bent or hunched posture, tension, or rigidity
• Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection

•  Clean clothing, appropriate to age, fit, season and occasion
•  Dirty, disheveled, or inappropriate to age, fit, season, or occasion
• Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection

•  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
• Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection

Rachel Adler Alcohol Use Disorder Shadow Health Objective Data Collection

Objective Data Collection: 21 of 21 (100%)
Assessed Vitals
– Temperature: Normal
– Blood Pressure: Normotensive
– Heart Rate: Normal
– Respiratory Rate: Normal
– O2 Saturation: Normal

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Inspected Eyes
– Pupillary Reaction: Normal
– Accommodation: Normal constriction and dilation

Inspected Injury
– Left Hand: Normal
– Left Wrist: Normal
– Right Hand: Normal
– Right Wrist: Normal

Inspected Upper Extremities for Self-harm or Abuse
– Observations: No visible evidence of self-harm or abuse
– Wounds Or Scars: No visible wounds or scars
– Location Of Visible Abnormality: No visible abnormality

Auscultated Breath Sounds
– Breath Sounds: Clear in all areas
– Adventitious Sounds: No adventitious sounds

Auscultated Heart Sounds
– Heart Sounds: S1 and S2 audible
– Extra Heart Sounds: No extra sounds
– Rate And Rhythm: Regular rate and rhythm

Palpated Radial Arteries
– Right: Vibration: No thrill
– Right: Amplitude: 2+ Expected
– Left: Vibration: No thrill
– Left: Amplitude: 2+ Expected

Tested Capillary Refill
– Right Hand: Less than 2 seconds
– Left Hand: Less than 2 seconds

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
– Attitude Toward Medical Staff: Generally open and cooperative

Assessed Speech
– Rate: Demonstrates appropriate or expected rate of speech
– Volume: Demonstrates appropriate or expected speech volume
– 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)

Assessed Thought Process
– 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
– To Person: Oriented to person
– To Place: Oriented to place
– To Time: Oriented to time
– To Situation: Oriented to situation

Assessed Serial Sevens
– Serial Sevens: Able to complete the series

Assessed Abstract Thinking
– Abstract Thinking: Demonstrates abstract thinking with similarities test

Assessed Memory
– Memory: Remote and immediate memory intact

Assessed Visuospatial Ability
– Visuospatial Ability: Visuospatial ability intact for interlocking shapes test

Assessed Insight
– Insight: Demonstrates full awareness of illness and willingness to seek treatment

Assessed Judgment
– Judgment: Demonstrates good judgment

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