Shadow Health Bipolar Disorder Lucas Callahan

Shadow Health Focused Exam: Bipolar Disorder Lucas Callahan Subjecve Data (page 1-27) Educaon/Empathy (pages 27-28) SBAR (page 28-29) Chief Complaint • Finding: Asked about chief complaint • Finding: Reports being brought in by police Why are you in the emergency department tonight? History of Present Illness • Finding: Followed up on incident • Finding: Reports looking into cars for government agents chasing him What were you doing when the police found you? • Finding: Reports having been in a grocery store parking lot Where were you when the police found you?2 • Finding: Reports knowing the police stopped him for running around and looking in cars Do you know why the police brought you in? • Finding: Denies having hurt himself or others Were you hurng anyone? • Finding: Denies having done anything illegal Were you doing anything illegal? • Finding: Followed up on government agents • Finding: Reports government is trying to imprison him for being enlightened Why are the government agents following you? • Finding: Reports government sees his enlightenment as a threat to their secrets Why are the government agents following you? • Finding: Asked about anxiety or paranoia • Finding: Denies anxiety or paranoia Are you feeling anxious or paranoid? • Finding: Reports high awareness of government agents chasing him What is making you anxious?3 • Finding: Asked about hallucinaons • Finding: Denies hallucinaons Do you ever see things others can't? • Finding: Asked about most recent substance use • Finding: Reports last substance use was about four days ago When was the last me you used substances? • Finding: Reports last substance use was cocaine What substance did you use four days ago? • Finding: Asked about recent sleep history • Finding: Reports not having slept for four days When was the last me you slept? • Finding: Asked about current energy levels • Finding: Reports current extremely high energy How would you describe your energy right now? • Finding: Asked about current mood • Finding: Reports current euphoria What kind of mood are you in?4 • Finding: Asked about onset of energy and mood • Finding: Reports high energy began a week ago How long have you been feeling this energec? • Finding: Reports euphoria began a week ago How long have you been feeling euphoric? Past Medical History • Finding: Asked about exisng health condions • Finding: Reports being diagnosed with depression What exisng health condions do you have? • Finding: Asked about typical moods • Finding: Reports periods of euphoria Do you have periods of feeling really good? • Finding: Reports periods of depression Do you have periods of feeling really bad? • Finding: Asked about typical energy levels5 • Finding: Reports periods of extremely low energy Do you have periods of low energy? • Finding: Reports periods of extremely high energy Do you have periods of high energy? • Finding: Asked about frequency of mood changes • Finding: Reports mood changes occur a couple of mes a year • How many mes a year do you experience mood changes? • Finding: Asked about last period of depression • Finding: Reports last depressive period ended a couple months ago When did your last period of depression end? • Finding: Reports last depressive period was a long one • How long was your last period of de