Lucas Callahan Bipolar Disorder Objective Data Collection
Assessment of Vital Signs
Table of Contents
Temperature:
– Normal body temperature
Blood Pressure:
– Blood pressure within normal range
Heart Rate:
– Heart rate is normal
Respiratory Rate:
– Breathing rate is normal
Oxygen Saturation:
– Oxygen levels in the blood are normal
Leg Examination:
– Right leg shows no visible abnormalities
– Left leg shows no visible abnormalities
– Both legs are symmetric in appearance
Nose Examination:
– Nose appears pink in color
– No discharge from the nose
– No additional abnormalities observed
Back Examination:
– No visible abnormalities on the back
Eye Examination:
– Pupillary reaction is normal
– Eyes show no additional abnormalities
Chest Examination:
– Chest appears symmetric
– No visible abnormalities on the chest
Arm Examination:
– No visible evidence of self-harm or abuse on the arms
Breath Sounds:
– Clear breath sounds in all areas
Heart Sounds:
– Normal heart sounds are audible
Capillary Refill:
– Capillary refill time is normal for both hands
Palpated Arteries:
– Arterial vibrations are within normal range
Abdomen Examination:
– No reported tenderness in the abdomen
– No palpable masses in the abdomen
– No additional observations noted
EKG Assessment:
– Sinus rhythm is regular
– No ST elevation observed
Lab Tests:
– Negative drug screen results
– Thyroid function tests within normal ranges
General Appearance:
– Maintains direct eye contact
– Upright posture without tension
– Clean and appropriate clothing
Attitude Towards Medical Staff:
– Generally open and cooperative attitude
Speech Assessment:
– Speech rate, volume, and articulation are normal
Mood and Affect:
– Stable mood with balanced affect
Thought Process:
– No disturbances in thought process observed
Thought Content:
– No disturbances in thought content noted
Orientation:
– Oriented to person, place, time, and situation
Serial Sevens Test:
– Able to complete the series
Abstract Thinking:
– Demonstrates abstract thinking
Memory:
– Intact remote and immediate memory
Visuospatial Ability:
– Intact visuospatial ability
Insight:
– Demonstrates full awareness of illness
Judgment:
– Demonstrates good judgment
Lucas Callahan Bipolar Disorder Objective Data Collection
- Normothermic
- Hyperthermic
- Hypothermic
- Normotensive
- Hypertensive
- Hypotensive
- Normal
- Tachycardic
- Bradycardic
- Normal
- Tachypnea
- Bradypnea
- Normal
- Hypoxemia
- No visible abnormal findings
- Redness
- Bruising or other discoloration
- Edema
- Visible mass
- Atrophy
- Hypertrophy
- No visible abnormal findings
- Redness
- Bruising or other discoloration
- Edema
- Visible mass
- Atrophy
- Hypertrophy
- Symmetric bilaterally
- Asymmetric
- Pink
- Red
- Bluish
- No discharge
- Clear discharge
- Bloody discharge
- Purulent discharge
- No additional visible abnormal findings
- Foreign body present
- Polyp
- Septum perforated
- Septum deviated
- Lesion
- No visible abnormal findings
- Rash
- Moles or skin tags
- Freckles, birthmark, or other discoloration
- Excessive dry or flaking skin
- Purpura
- Striae
- Scratching
- Bruising
- Normal
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
- Normal constriction and dilation
- Unequal or no pupillary constriction
- Unequal or no pupillary dilation
- White
- Yellow Tint
- Redness
- Symmetric
- Asymmetric
- No visible abnormal findings
- Redness
- Rash
- Moles or skin tags
- Masses (warts, cysts, or tumors)
- Freckles, birthmark, or other discoloration
- Excessive dry or flaking skin
- Purpura
- Striae
- Bruising
- Scarring
- No visible evidence of self-harm or abuse
- Evidence of self-harm
- 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
- Irregular rate
- Arrhythmia
- Less than 2 seconds
- Greater than 2 seconds
- Less than 2 seconds
- Greater than 2 seconds
- No Thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No Thrill
- Thrills
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No Thrill
- Thrills
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No Thrill
- Thrills
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- None Reported
- Tenderness Reported
- No quadrants tender
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
- No additional observations
- Masses
- Guarding
- Distension
- No palpable mass
- Palpable mass
- No palpable mass
- Right upper quadrant
- Right lower quadrant
- Left upper quadrant
- Left lower quadrant
- Around umbilicus
- Regular
- Irregular
- No ST elevation
- ST elevation present
- Positive for substances
- Negative for substances
- Both levels within normal ranges
- Thyroxine-binding globulin elevated
- Thyroxine-binding globulin low
- Thyroid-stimulating hormone (TSH) elevated
- Thyroid-stimulating hormone (TSH) low
- Direct eye contact
- Indirect or no eye contact
- Upright posture without tension or rigidity
- Bent or hunched posture, tension, or rigidity
- Clean clothing, appropriate to age, fit, season, and occasion
- Dirty, disheveled, or inappropriate to age, fit, season, or occasion
- 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
