12/02/2024, 19:05 | Shadow Health® │ Digital Clinical Experiences™ from Elsevier

Focused Exam: Alcohol Use Disorder Results | Completed

Introduction to the Canadian Health Care System and Nursing in Canada (Mental Health)- Winter 2024, PNUR 9101
Return to Assignment (/assignments/939209/)

Your Results Turn In (/assignment_attempts/16126367/choos

Reopen (/assignment_attempts/16126367/reopen)

Lab Pass (/assignment_attempts/16126367/lab_pass.pd

Overview
Subjective Data Collection: 47 of 51 (92.2%)
Transcript

Subjective Data Collection

Hover To Reveal... Indicates an item that
Objective Data Collection you found.
Hover over the Patient Data items Indicates an item that
Education & Empathy below to reveal important is available to be found.
information, including Pro Tips and
Documentation Example Questions.

SBAR

Reflections
Category Scored Items Patient Data
Student Survey Not Scored

Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview with yield better patient data. The following details
this patient. are facts of the patient's case.

Chief Complaint

Established chief complaint and reason Reports car accident

for admittance 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 Reports drinking before accident

car accident

https://app.shadowhealth.com/assignment_attempts/16126367 1/7
12/02/2024, 19:05 | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
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

did not care
Reports have driven in past a
she did not care if she injured h

Followed up on impaired driving - risk for self harm Reports has had enough of lif
got hurt/died
Reports had not thought abou
Reports since accident, not s
what she did

Asked about onset and duration of pain Reports pain started immedia
Reports accident was last nig
Reports accident was at 10 p

Asked about location of pain Reports pain is in right wrist

Asked about aggravating factors of pain Reports increased pain when

wrist
Reports increased pain when
small ones such as a hairbrush

Asked about treatment and relieving factors of pain Reports rest improves pain
Reports ibuprofen has signific
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

Reports pain without medicat

Past Medical History

Asked about existing health conditions Reports no known health prob

Asked about history of mental health Denies previous history of me

Denies past depression
Reports feeling anxious over
not sought treatment/counselin
Reports can not deal with stre
general

https://app.shadowhealth.com/assignment_attempts/16126367 2/7
12/02/2024, 19:05 | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Reports that she does not care what happens to her
anymore (passive suicidal ideation)

Followed up on stress issues Reports stress over parental

Reports stress over school
Reports stress over grades

Followed up on self harm Reports no active suicidal tho

Denies past suicide attempts

Followed up on confusion about life/death Reports feeling it may be bett

put up with the stress of life any
Reports not caring that she p
injury/death by drinking and dri
Reports feeling like it would b
car accident

Followed up on passive suicidal ideation Reports feels unsure of future

Reports tired of mother being
Reports fear of failure and dis
Reports low self esteem

Asked about allergies Reports peanut allergy

Denies environmental allergie
Denies latex allergy

Followed up on peanut allergy Reports reaction is itchy mou

Reports avoiding peanuts

Asked about previous hospitalizations Denies previous hospitalizatio

Asked specifically about medication allergies Denies medication allergies

Home Medications

Asked about home medications Reports occasional ibuprofen

Reports taking oral contracep
Denies taking vitamins
Denies taking herbal supplem

Followed up on ibuprofen Reports taking ibuprofen

Reports ibuprofen dosage: 20
Reports ibuprofen number of
Reports ibuprofen frequency:
cramps
Denies ibuprofen side effects

https://app.shadowhealth.com/assignment_attempts/16126367 3/7
12/02/2024, 19:05 | Shadow Health® │ Digital Clinical Experiences™ from Elsevier

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 d

Reports father has no major m
Reports maternal grandfather

Social History

Asked about education Currently a college student

Is a junior
Reports being a good studen
Reports majoring in physics

Asked about work Denies having a job outside o

Asked about family and support system Describes relationship with pa

Reports arguing with her mot
late
Reports mother is very judgem
expectations
Reports interacts minimally w
father for support
Reports has one sibling (broth
sees him on holidays
Reports feeling like she has f

Asked about living situation Reports living in a dorm

Reports living with one roomm

Asked about exercise Reports exercising 3 - 4 days

Prefers running
Occasionally goes to the gym

Asked about diet Reports typically skipping bre

Reports fruit or salad for typic
Reports a small dinner, typica

Asked about appetite Reports loss of appetite

Asked about last menstrual period Reports LMP was 2 weeks ag

https://app.shadowhealth.com/assignment_attempts/16126367 4/7
12/02/2024, 19:05 | Shadow Health® │ Digital Clinical Experiences™ from Elsevier

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 ni

Followed up about alcohol use Reports frequent alcohol use

Reports drinking beer or wine

Followed up on frequency of alcohol use Reports drinking 3 - 4 nights a

Reports drinking up to 5 drink
Reports usually drinks with ot

Followed up on passing out from drinking Reports occasionally passing

Reports passing out twice in t
Reports has little to no memo
passing out
Reports no significant injuries
when passed out from drinking

Followed up on frequency of hangovers Reports feeling hungover mo

drinks

CAGE Assessment

Asked about cutting down on drinking Reports that she has not tried
Reports when she drinks she

Asked about others perceptions of drinking Reports that since she mostly
cares about her drinking
Reports that she rarely drinks
they do not know how much sh

Asked about feelings around drinking Reports that she drinks to fee
Reports her drinking does no
not feel bad or guilty for drinkin

Asked about drinking first thing in the morning Denies drinking first thing in t

Review of Systems

https://app.shadowhealth.com/assignment_attempts/16126367 5/7
12/02/2024, 19:05 | Shadow Health® │ Digital Clinical Experiences™ from Elsevier

Asked about general symptoms Denies fever

Denies chills
Denies night sweats
Reports occasional fatigue

Asked about HEENT system Denies impaired vision

Denies impaired hearing

Asked about respiratory system Denies cough

Denies shortness of breath
Denies dyspnea on exertion
Denies wheezing

Asked about cardiovascular system Denies chest pain

Denies palpitations
Denies edema
Denies claudication

Asked about integumentary system Denies changes in hair

Denies changes in skin
Denies changes in nails
Denies rashes
Denies pruritus or easy bruisi
Denies pigmentation changes

Asked about gastrointestinal system Reports no abdominal pain

Reports no nausea
Denies difficulty swallowing
Denies vomiting
Denies constipation
Denies diarrhea
Denies changes in stool or bo

Asked about musculoskeletal system Reports recent injury - sprain

Denies joint pain
Denies erythema
Denies edema of joints prior t

Asked about neurological system Denies weakness

Denies frequent headaches
Reports slight tingling in finge
Denies syncope, dizziness, fa
Denies changes in coordinati
Denies changes in memory
Denies recent falls

Comments

https://app.shadowhealth.com/assignment_attempts/16126367 6/7
12/02/2024, 19:05 | Shadow Health® │ Digital Clinical Experiences™ from Elsevier

If your instructor provides individual feedback on this assignment, it will appear here.

About Shadow Health (https://evolve.elsevier.com/education/simulations/shadow-health/)

Terms and Conditions (https://www.elsevier.com/legal/elsevier-website-terms-and-conditions) (https://www
Privacy Policy (https://www.elsevier.com/legal/privacy-policy)
Support and Contact (https://service.elsevier.com/app/home/supporthub/shadow-health/) Patents (/static/patents)
s://www.elsevier.com/)

Cookies are used by this site. Cookie Settings.

Copyright © 2024 Elsevier Inc., its licensors, and contributors. All rights are reserved, including those for text and data mining, AI training,
and similar technologies.

https://app.shadowhealth.com/assignment_attempts/16126367 7/7