Focused Exam Bipolar Disorder Completed Shadow Health

Objective Data Collection: 28 of 28 (100%) Correct Partially correct Incorrect Missed Assessed Vitals 1 of 1 point Temperature (1/5 point) *Normothermic Hyperthermic Hypothermic Blood Pressure (1/5 point) *Normotensive Hypertensive Hypotensive Heart Rate (1/5 point) *Normal Tachycardic Bradycardic Respiratory Rate (1/5 point) *Normal Tachypnea Bradypenea O2 Saturation (1/5 point) Normal Hypoxemia   Inspected Legs 1 of 1 point Right: Appearance (1/3 point) *No visible abnormal findings Redness Bruising or other discoloration Edema Visible mass Atrophy Hypertrophy Left: Appearance (1/3 point) *No visible abnormal findings Redness Bruising or other discoloration Edema Visible mass Atrophy Hypertrophy Symmetry (1/3 point) *Symmetric bilaterally Asymmetric Inspected Nose 1 of 1 point Color (1/3 point) Discharge (1/3 point) Inspected Nose 1 of 1 point Color (1/3 point) *Pink Red Bluish Discharge (1/3 point) *No discharge Clear discharge Bloody discharge Purulent discharge Observations (1/3 point) *No additional visible abnormal findings Foreign body present Polyp Septum perforated Septum deviated Lesion Inspected Back 1 of 1 point Appearance (1/1 point) No visible abnormal findings Rash Moles or skin tags Freckles, birthmark, or other discoloration Excessive dry or flaking skin Purpura Striae *Scratching Bruising Inspected Eyes 1 of 1 point Pupillary Reaction (1/3 point) *Normal Unequal Irregular Miosis Mydriasis Non-reactive to light Reaction (1/3 point) *Normal constriction and dilation Unequal or no pupillary constriction Unequal or no pupillary dilation Sclera (1/3 point) White Yellow Tint Redness Inspected Chest 1 of 1 point Symmetry (1/2 point) *Symmetric Appearance (1/2 point) *No visible abnormal findings Asymmetric Rash Moles or skin tags Masses (warts, cysts, or tumors) Freckles, birthmark, or other discoloration Excessive dry or flaking skin Purpura Striae Bruising Scarring Inspected Arms 1 of 1 point Observations (1/3 point) Wounds Or Scars (1/3 point) No visible evidence of self-harm or abuse No visible wounds or scars Evidence of self-harm 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 Auscultated Breath Sounds 1 of 1 point Breath Sounds (1/2 point) Adventitious Sounds (1/2 point) Clear in all areas No adventitious sounds Diminished in some areas. Wheezing Absent in some areas Fine crackles Stridor Rhonchi Rales ✔ Auscultated Heart Sounds 1 of 1 point Heart Sounds (1/3 point) Extra Heart Sounds (1/3 point) *S1 and S2 audible * No extra sounds S1, S2, and S3 audible Gallops S1, S2, and S4 audible Murmur S1, S2, S3, and S4 audible Friction rub Valve clicks Rate And Rhythm (1/3 point) *Regular rate and rhythm Irregular rate Arrhythmia ✓ Palpated capillary Refill 1 of 1 point Right Hand (1/2 point) Left Hand (1/2 point) *Less than 2 seconds * Less than 2 seconds Greater than 2 seconds Greater than 2 seconds ✓ Palpated Radial Arteries 1 of 1 point Right: Vibration (1/4 point) Right: Amplitude (1/4 point) *No Thrill 0 Absent Thrill 1+ Diminished or barely palpable *2+ Expected 3+ Increased 4+ Bounding pulse Left: Vibration (1/4 point) Left: Amplitude (1/4 point) *No Thrill 0 Absent Thrills 1+ Diminished or barely palpable *2+ Expected 3+ Increased 4+ Bounding pulse ✓ Palpated Dorsalis Pedis Arteries 1 of 1 point Right: Vibration (1/4 point) Right: Amplitude (1/4 point) *No Thrill 0 Absent Thrills 1+ Diminished or barely palpable *2+ Expected 3+ Increased 4+ Bounding pulse Left: Vibration (1/4 point) Left: Amplitude (1/4 point) Palpated Abdomen 1 of 1 point Tenderness (1/5 point) Location Of Tenderness (1/5 point) *None Reported *No quadrants tender Tenderness Reported Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant Observations (1/5 point) Presence Of Unexpected Mass (1/5 point) *No additional observations No palpable mass Masses Palpable mass Guarding Location Of Mass (1/5 point) Distension * No palpable mass Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant Around umbilicus Performed EKG 1 of 1 point Sinus Rhythm (1/2 point) ST Changes (1/2 point) *Regular *No ST elevation Irregular ST elevation present Assessed Labs 1 of 1 point Drug Screen Results (1/2 point) Thyroid Function Tests (1/2 point) Positive for substances *Both levels within normal ranges *Negative for substances Thyroxine-binding globulin elevated Thyroxine-binding globulin low Thyroid-stimulating hormone (TSH) elevated Thyroid-stimulating hormone (TSH) low 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 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 F*requent 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) ✓ Assessed Thought Process 1 of 1 point Thought Process (1/1 point) No presence of thought process disturbances It focuses on thought content, orientation, serial sevens, abstract thinking, and memory. Each section has multiple checkboxes for different observations, with corresponding labels. The purpose of the checklist is to record findings during a mental status examination. ✓ 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 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) ✓ Demonstrstrates good judgment Judgment poor or impaired judgment