Sales Tax Notification: Elsevier Inc. DBA Shadow Health charges applicable sales tax as required by state and local regulations. If you are using Safari and have issues with audio in your assignment, please click here for assistance. Click here for more information (https://support.shadowhealth.com/hc/enus/articles/360009548313) Focused Exam: Alcohol Use Disorder Results | Completed Mental Health Concepts in Nursing - January 2022, nur3525-ku_pem_nur3525d1101102022 Return to Assignment (/assignments/615801/) Your Results Turn In (/assignment_attempts/11517320/choos Lab Pass (/assignment_attempts/11517320/lab_pass. Overview Subjective Data Collection: 50 of 51 (98.0%) Transcript Subjective Data Collection Hover To Reveal... Indicates an item that you found. Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Indicates an item that is available to be found. Objective Data Collection Education & Empathy QSEN Competencies Documentation SBAR Category Scored Items Reflections Patient Data Not Scored Student Survey Experts selected these topics as essential components of a strong, thorough interview with this patient. A combination of open and closed questions will yie better patient data. The following details are facts o patient's case. Chief Complaint Established chief complaint and reason for admittance Reports car accident Reports injury Reports passive suicidal ideation History of Present Illness 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 wa mad at her girlfriend and could not take any more Asked about driving impaired Reports knew she was driving under the influenc but did not care Reports have driven in past after drinking, but thi 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 i she got hurt/died 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 Asked about aggravating factors of pain Reports pain is in right wrist 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 Past Medical History Asked about existing health conditions Asked about history of mental health Reports no known health problems 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 lif 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 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 Home Medications 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 Family History 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 Social History Asked about education Currently a college student Is a junior Reports being a good student Reports majoring in physics 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 - sees 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 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 CAGE Assessment 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 sh 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 Review of Systems 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 Denies difficulty swallowing Denies vomiting Denies constipation Denies diarrhea Denies changes in stool or bowel patterns Asked about review of systems for musculoskeletal Reports recent injury - sprained (R) wrist Denies joint pain Denies erythema Denies edema of joints prior to wrist injury Asked about review of systems for neurological Denies weakness Denies frequent headaches Reports slight tingling in fingers on right hand Denies syncope, dizziness, fainting, or vertigo Denies changes in coordination Denies changes in memory Denies recent falls Comments If your instructor provides individual feedback on this assignment, it will appear here. 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