Focused Exam_ Alcohol Use Disorder _ Completed _ Shadow Health

Subjective Data Collection: 51 of 51 (100.0%) Chief Complaint History of Present Illness Your Results Lab Pass (/assignment_attempts//lab_ Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy QSEN Competencies Documentation SBAR Reflections Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of t patient's case. Established chief complaint and reason for admittance Reports car accident Reports injury Reports passive suicidal ideation Followed up on details of car accident Reports loss of consciousness Reports being unsure of how the accident happened Reports wearing seatbelt Reports being the driver - no other passengers in car Reports was told she would get a ticket for DUI Followed up on alcohol use just prior to car accident Reports drinking before accident Reports being unsure of how many drinks - "at least 5" Reports was drinking with friends at a party Reports left party to drive home because she was mad at her girlfriend and could not take any more Asked about driving impaired Reports knew she was driving under the influence but did not care Reports have driven in past after drinking, but this time she did not care if she injured herself Followed up on impaired driving - risk for self harm Reports has had enough of life and did not care if she got hurt/died Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. This study source was downloaded by from CourseH on :39:52 GMT -05:00 Past Medical History Reports had not thought about self harm before accident Reports since accident, not sure what to think about what she did Asked about onset and duration of pain Reports pain started immediately after accident Reports accident was last night Reports accident was at 10 pm Asked about location of pain Reports pain is in right wrist Asked about aggravating factors of pain Reports increased pain when bending or twisting (R) wrist Reports increased pain when trying to lift items, even small ones such as a hairbrush Asked about treatment and relieving factors of pain Reports rest improves pain Reports ibuprofen has significantly reduced pain Reports wearing sling helps Asked about characteristics of pain Reports pain is aching Denies sharp or shooting pain Asked about severity of pain Reports current pain level is 2/10 Reports pain without medication was 8/10 Asked about existing health conditions Reports no known health problems Asked about history of mental health Denies previous history of mental illness diagnoses Denies past depression Reports feeling anxious over the past six months - has not sought treatment/counseling Reports can not deal with stress of school and life in general Reports that she does not care what happens to her anymore (passive suicidal ideation) Followed up on stress issues Reports stress over parental relationships Reports stress over school Reports stress over grades Followed up on self harm Reports no active suicidal thoughts prior to accident Denies past suicide attempts Followed up on confusion about life/death Reports feeling it may be better if she "does not have to put up with the stress of life anymore" Reports not caring that she put herself at risk for injury/death by drinking and driving Reports feeling like it would be better if she had died in car accident This study source was downloaded by from CourseH on :39:52 GMT -05:00 Home Medications Family History Social History Followed up on passive suicidal ideation Reports feels unsure of future Reports tired of mother being so critical of her Reports fear of failure and disappointing others Reports low self esteem Asked about allergies Reports peanut allergy Denies environmental allergies Denies latex allergy Asked about previous hospitalizations Denies previous hospitalizations Asked specifically about medication allergies Denies medication allergies Followed up on peanut allergy Reports reaction is itchy mouth and throat Reports avoiding peanuts Asked about home medications Reports occasional ibuprofen for menstrual cramps Reports taking oral contraceptive Denies taking vitamins Denies taking herbal supplements Followed up on ibuprofen Reports taking ibuprofen Reports ibuprofen dosage: 200 mg Reports ibuprofen number of pills: 2 at a time Reports ibuprofen frequency: monthly, for menstrual cramps Denies ibuprofen side effects Followed up on oral contraceptive Reports taking Ortho Tri-Cyclen Lo Reports Ortho Tri-Cyclen Lo frequency: 1 pill per day Denies skipping pills Reports taking pill in the morning Denies Ortho Tri-Cyclen Lo side effects Asked about relevant family history Reports mother has anxiety disorder Reports father has no major medical issues Reports maternal grandfather had a history of alcoholism Asked about education Currently a college student Is a junior Reports being a good student Reports majoring in physics This study source was downloaded by from CourseH on :39:52 GMT -05:00 Asked about work Denies having a job outside of school Asked about family and support system Describes relationship with parents as "decent" Reports arguing with her mother more frequently as of late Reports mother is very judgemental and has high expectations Reports interacts minimally with mother and turns to father for support Reports has one sibling (brother) who lives out of state - see him on holidays Reports feeling like she has few close friends at school Asked about living situation Reports living in a dorm Reports living with one roommate Asked about exercise Reports exercising 3 - 4 days a week Prefers running Occasionally goes to the gym to workout Asked about diet Reports typically skipping breakfast Reports fruit or salad for typical lunch Reports a small dinner, typically a sandwich Asked about appetite Reports loss of appetite Asked about last menstrual period Reports LMP was 2 weeks ago Asked about sexual activity Reports not currently sexually active Reports last sexual activity was 3 months ago Reports being single Reports is on birth control pills and practices safe sex Denies STDs, tested 3 months ago when getting new prescription for birth control pills Denies any past pregnancies or ABs Asked about substance use Reports alcohol use Denies illicit drug use Denies use of tobacco and nicotine products Followed up about alcohol use Reports frequent alcohol use Reports drinking beer or wine coolers Followed up on frequency of alcohol use Reports drinking 3 - 4 nights a week Reports drinking up to 5 drinks at a time Reports usually drinks with others, may drink alone Followed up on passing out from drinking Reports occasionally passing out from drinking Reports passing out twice in the last month Reports has little to no memory of events prior to passing out This study source was downloaded by from CourseH on :39:52 GMT -05:00 CAGE Assessment Review of Systems Reports no significant injuries (prior to car accident) when passed out from drinking Followed up on frequency of hangovers Reports feeling hungover most of the time when she drinks Asked about cutting down on drinking Reports that she has not tried to cut down on drinking Reports when she drinks she tends to eat less Asked about others perceptions of drinking Reports that since she mostly drinks with friends, no one cares about her drinking Reports that she rarely drinks in front of parents - so they do not know how much she drinks Asked about feelings around drinking Reports that she drinks to feel better or to feel nothing Reports her drinking does not hurt anyone, so she does not feel bad or guilty for drinking Asked about drinking first thing in the morning Denies drinking first thing in the morning Asked about general symptoms Denies fever Denies chills Denies night sweats Reports occasional fatigue Asked about review of systems for HEENT Denies impaired vision Denies impaired hearing Asked about review of systems for respiratory Denies cough Denies shortness of breath Denies dyspnea on exertion Denies wheezing Asked about review of systems for cardiovascular Denies chest pain Denies palpitations Denies edema Denies claudication Asked about review of systems for skin, hair, and nails Denies changes in hair Denies changes in skin Denies changes in nails Denies rashes Denies pruritus or easy bruising Denies pigmentation changes Asked about review of systems for gastrointestinal Reports no abdominal pain Reports no nausea