Rachel Adler Alcohol Use Disorder shadow health
Objective Data Collection: 21 of 21 (100%)
Assessed Vitals
Temperature: Normothermic
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
Liam Fitzgerald Telehealth Follow Up Sick Visit Shadow Health Transcript
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Rachel Adler Alcohol Use Disorder shadow health
Objective Data Collection: 21 of 21 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
- Normothermic
- Hyperthermic
- Hypothermic
- Normotensive
- Hypertensive
- Hypotensive
- Normal
- Tachycardic
- Bradycardic
- 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