Focused Exam: PTSD Nicole Diaz shadow health Objective Data

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%)

 Partially correct


 Assessed Vitals
1 of 1 point

Temperature (1/5 point)



Blood Pressure (1/5 point)


Heart Rate (1/5 point)


Respiratory Rate (1/5 point)


O2 Saturation (1/5 point)


 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

Left Leg (1/2 point)

 No edema

 Auscultated Carotid Arteries
1 of 1 point

Right (1/2 point)

 No bruit

Left (1/2 point)

 No 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
 Fine crackles

 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
 Friction rub
 Valve clicks

Rate And Rhythm (1/3 point)

 Regular rate and rhythm
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)


 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


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