Shadow Health Focused Exam: Rachel Adler – ETOH Chief Complaint Finding: Established chief complaint and reason for admittance Finding: Reports car accident Example Question: Why were you admitted? Finding: Reports injury Example Question: What caused your injury? Finding: Reports passive suicidal ideation Example Question: What brings you in today? History of Present Illness Finding: Followed up on details of car accident Finding: Example Question: Did you lose consciousness during the car accident? Finding: Reports being unsure of how the accident happened Example Question: Do you know what caused the car accident? Finding: Reports wearing seatbelt Example Question: Were you wearing a seatbelt? Finding: Reports being the driver - no other passengers in car Example Question: Who was driving before the car accident? Finding: Reports was told she would get a ticket for DUI Example Question: What caused the car accident? Finding: Followed up on alcohol use just prior to car accident Finding: Reports drinking before accident Example Question: Were you drinking before the accident? Finding: Reports being unsure of how many drinks - "at least 5" Example Question: How much did you drink before the accident? Finding: Reports was drinking with friends at a party Example Question: Who were you drinking with? Finding: Reports left party to drive home because she was mad at her girlfriend and could not take any more Example Question: Why did you leave the party? Finding: Asked about driving impaired Finding: Reports knew she was driving under the influence but did not care Example Question: Did you know you were too drunk to drive? Finding: Reports have driven in past after drinking, but this time she did not care if she injured herself Example Question: Did you care that you were driving under the influence? Finding: Followed up on impaired driving - risk for self harm Finding: Reports has had enough of life and did not care if she got hurt/died Example Question: Did you drive under the influence in order to hurt yourself? Finding: Reports had not thought about self harm before accident Example Question: Have you ever wanted to hurt yourself before the accident? Finding: Reports since accident, not sure what to think about what she did Example Question: How do you feel since the accident? Finding: Asked about onset and duration of pain Finding: Reports pain started immediately after accident Example Question: When did you last experience the pain? Finding: Reports accident was last night Example Question: When did the car accident happen? Finding: Reports accident was at 10 pm Example Question: When did the car accident happen? Finding: Asked about location of pain Finding: Reports pain is in right wrist Example Question: Does your wrist hurt? Finding: Asked about aggravating factors of pain Finding: Reports increased pain when bending or twisting (R) wrist Example Question: Is your pain worse with movement? Finding: Reports increased pain when trying to lift items, even small ones such as a hairbrush Example Question: Is your pain worse with movement? Finding: Asked about treatment and relieving factors of pain Finding: Reports rest improves pain Example Question: Does lying down help your pain? Finding: Reports ibuprofen has significantly reduced pain Example Question: Has ibuprofen helped your pain? Finding: Reports wearing sling helps Example Question: Has wearing the sling helped your pain? Finding: Asked about characteristics of pain Finding: Reports pain is aching Example Question: Is the pain aching? Finding: Denies sharp or shooting pain Example Question: Do you have shooting pain? Finding: Asked about severity of pain Finding: Reports current pain level is 2/10 Example Question: How would you rate your pain? Finding: Reports pain without medication was 8/10 Example Question: How would you rate your pain without medication? Past Medical History Finding: Asked about existing health conditions Finding: Reports no known health problems Example Question: What health problems do you have? Finding: Asked about history of mental health Finding: Denies previous history of mental illness diagnoses Example Question: Do you have a history of psychiatric illness? Finding: Denies past depression Example Question: Have you experienced any depression or sadness? Finding: Reports feeling anxious over the past six months - has not sought treatment/counseling Example Question: Have you felt anxious? Finding: Reports can not deal with stress of school and life in general Example Question: Is your life stressful?