Alcohol Use Disorder - Rachel Adler Shadow Health - Subjective Data Collection

Alcohol Use Disorder – Rachel Adler Shadow Health – Subjective Data Collection

Subjective Data Collection: 51 of 51 (100.0%)

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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 the patient’s case.

Chief Complaint

– Established chief complaint and reason for admittance: Rachel Adler has Alcohol Use Disorder.

– Reports car accident: The patient was involved in a car accident.

– Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.

– Example Question: Why were you admitted?

– Reports injury: The patient sustained injuries in the accident.

– Example Question: What caused your injury?

– Reports passive suicidal ideation: The patient expresses thoughts of passive suicidal ideation.

NRNP 6645: Psychotherapy with Multiple Modalities Final Exam

– Example Question: What brings you in today?

History of Present Illness

– Followed up on details of car accident: Further inquired about the car accident.

– Reports loss of consciousness: The patient experienced a loss of consciousness during the accident.

– Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

– Example Question: Did you lose consciousness during the car accident?

– Reports being unsure of how the accident happened: The patient is uncertain about the cause of the car accident.

– Example Question: Do you know what caused the car accident?

– Reports wearing seatbelt: The patient was wearing a seatbelt during the accident.

– Example Question: Were you wearing a seatbelt?

– Reports being the driver – no other passengers in the car: The patient was the sole occupant and driver of the vehicle.

– Example Question: Who was driving before the car accident?

– Reports was told she would get a ticket for DUI: The patient was informed that she would receive a DUI ticket.

– Example Question: What caused the car accident?

– Followed up on alcohol use just prior to car accident: Further inquired about alcohol use before the car accident.

– Reports drinking before accident: The patient consumed alcohol before the accident.

– Example Question: Were you drinking before the accident?

– Reports being unsure of how many drinks – “at least 5”: The patient is uncertain about the exact number of drinks but estimates at least 5.

– Example Question: How much did you drink before the accident?

– Reports was drinking with friends at a party: The patient was drinking with friends at a party.

– Example Question: Who were you drinking with?

– Reports left party to drive home because she was mad at her girlfriend and could not take any more: The patient left the party and decided to drive home due to anger towards her girlfriend and emotional distress.

– Example Question: Why did you leave the party?

– Followed up on impaired driving – risk for self-harm: Further inquired about impaired driving and the risk for self-harm.

– Reports knew she was driving under the influence but did not care: The patient was aware that she was driving under the influence but did not have concerns about it.

– Example Question: Did you know you were too drunk to drive?

– Reports have driven in the past after drinking, but this time she did not care if she injured herself: The patient acknowledges previous instances of driving after drinking, but this time, she was indifferent to the possibility of self-injury.

– Example Question: Did you care that you were driving under the influence?

– Followed up on impaired driving – risk for self-harm: Further inquired about impaired driving and the risk for self-harm.

– Reports has had enough of life and did not care if she got hurt/died: The patient expresses feelings of having had enough of life and no longer caring about getting hurt or dying.

– Pro Tip: Asking a patient about

the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

– Example Question: Did you drive under the influence in order to hurt yourself?

– Reports had not thought about self-harm before the accident: The patient indicates that she had not previously contemplated self-harm before the accident.

– Example Question: Have you ever wanted to hurt yourself before the accident?

– Reports since accident, not sure what to think about what she did: The patient is unsure about her feelings and thoughts regarding her actions since the accident.

– Example Question: How do you feel since the accident?

– Followed up on onset and duration of pain: Further inquired about the onset and duration of pain.

– Reports pain started immediately after the accident: The patient’s pain began immediately after the car accident.

– Example Question: When did you last experience the pain?

– Reports accident was last night: The car accident occurred last night.

– Example Question: When did the car accident happen?

– Reports accident was at 10 pm: The car accident took place at 10 pm.

– Example Question: When did the car accident happen?

– Followed up on location of pain: Further inquired about the location of pain.

– Reports pain is in right wrist: The patient experiences pain in the right wrist.

– Example Question: Does your wrist hurt?

– Followed up on aggravating factors of pain: Further inquired about factors that worsen the pain.

– Reports increased pain when bending or twisting (R) wrist: The pain worsens when the right wrist is bent or twisted.

– Example Question: Is your pain worse with movement?

– Reports increased pain when trying to lift items, even small ones such as a hairbrush: The pain intensifies when attempting to lift objects, including small items like a hairbrush.

– Example Question: Is your pain worse with movement?

– Followed up on treatment and relieving factors of pain: Further inquired about treatment and factors that alleviate the pain.

– Reports rest improves pain: The patient experiences pain relief when at rest.

– Example Question: Does lying down help your pain?

– Reports ibuprofen has significantly reduced pain: Ibuprofen has been effective in reducing the patient’s pain.

– Example Question: Has ibuprofen helped your pain?

– Reports wearing sling helps: Wearing a sling has been helpful in managing the pain.

– Example Question: Has wearing the sling helped your pain?

– Followed up on characteristics of pain: Further inquired about the characteristics of the pain.

– Reports pain is aching: The pain is described as aching.

– Example Question: Is the pain aching?

– Denies sharp or shooting pain: The patient does not experience sharp or shooting pain.

– Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness.

– Example Question: Do you have shooting pain?

– Followed up on severity of pain: Further inquired about the severity of the pain.

– Reports current pain level is 2/10: The current pain level is rated at 2/10.

– Example Question: How would you rate your pain?

– Reports pain without medication was 8/10: The pain level without medication was 8/10.

on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

– Example Question: How would you rate your pain without medication?

Past Medical History

– Asked about existing health conditions: Inquired about any existing health conditions.

– Reports no known health problems: The patient has no known health problems.

– Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

– Example Question: What health problems do you have?

– Asked about history of mental health: Inquired about the patient’s history of mental health.

– Denies previous history of mental illness diagnoses: The patient denies any previous diagnoses of mental illness.

– Example Question: Do you have a history of psychiatric illness?

– Denies past depression: The patient denies experiencing depression in the past.

– Example Question: Have you experienced any depression or sadness?

– Reports feeling anxious over the past six months – has not sought treatment/counseling: The patient reports feeling anxious for the past six months but has not sought treatment or counseling.

– Example Question: Have you felt anxious?

– Reports can not deal with stress of school and life in general: The patient expresses difficulty in coping with the stress of school and life in general.

– Example Question: Is your life stressful?

– Reports that she does not care what happens to her anymore (passive suicidal ideation): The patient indicates that she no longer cares about her well-being or what happens to her, suggesting passive suicidal ideation.

– Example Question: How do you cope with stress?

– Followed up on stress issues: Further inquired about stress-related issues.

– Reports stress over parental relationships: The patient experiences stress related to parental relationships.

– Example Question: How do you get along with your parents?

– Reports stress over school: The patient is stressed about school.

– Example Question: Can you tell me about school?

– Reports stress over grades: The patient is stressed about her grades.

– Example Question: Have you been stressed about your grades?

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Alcohol Use Disorder – Rachel Adler Shadow Health – Subjective Data Collection