Focused Exam: PTSD Nicole Diaz shadow health Objective Data
Focused Exam: PTSD Nicole Diaz shadow health Objective Data
Objective Data Collection: 19 of 19 (100%)
Correct
Partially correct
Incorrect
Missed
Assessed Vitals
1 of 1 point
Temperature (1/5 point)
Normothermic
Hyperthermic
Hypothermic
ORDER SHADOW HEALTH HELP
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 Upper Extremities
1 of 1 point
Observations (1/3 point)
No visible evidence of self-harm or abuse
Evidence of self-harm
Evidence of abuse
Wounds Or Scars (1/3 point)
No visible wounds or scars
Wound visible
Scar visible
Location Of Visible Abnormality (1/3 point)
No visible abnormality
Right upper arm
Right lower arm
Right wrist
Right hand
Left upper arm
Left lower arm
Left wrist
Left hand
Inspected Legs
1 of 1 point
Right Leg (1/2 point)
No edema
Pitting
Non-pitting
Left Leg (1/2 point)
No edema
Pitting
Non-pitting
Auscultated Carotid Arteries
1 of 1 point
Right (1/2 point)
No bruit
Bruit
Left (1/2 point)
No bruit
Bruit
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
Arrhythmia
Focused Exam: PTSD Nicole Diaz shadow health Objective Data
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
Focused Exam: PTSD Nicole Diaz shadow health Objective Data
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)
Focused Exam: PTSD Nicole Diaz shadow health Objective Data
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
Focused Exam: PTSD Nicole Diaz shadow health Objective Data
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)
ORDER SHADOW HEALTH HELP HERE
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
Focused Exam: PTSD Nicole Diaz shadow health Objective Data
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
Focused Exam: PTSD Nicole Diaz shadow health Objective Data
