1/13/2020 Focused Exam: Bipolar Disorder | In Progress Attempt | Shadow Health
Shadow Health will be performing planned maintenance this Friday, from 7:00am until 7:30am Eastern. During this time (/site_notice_dismissals?from_flash=true&site_noti
assignment attempts will be disabled. Thank you for helping us to improve your Shadow Health experience!
Focused Exam: Bipolar Disorder (Part 2 of 2)
Therapeutic Intervention III - Winter 2020, NUR 304
Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning proces
This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the p
Documentation Review
E D Nursing
ED Nursing Note
Note Mental
Student Response Model Documentation
Status Note SBAR
Chief Complaint Patient was brought in by police due to erratic behavior Lucas Callahan is a 25-year-old man who was brought to
Shadow General Hospital at 11:30 PM; he was taken here
-bouts of depression a 'couple' times of the year policemen who found his behavior erratic. He denies havi
illness or a need to be in the hospital.
History of Present
-Patient reports not sleeping for past 4 days, sleeps only for a Presents to the ED today after being brought in by local la
Illness
'couple of hours' when patient does sleep enforcement. He was found in a grocery store parking lot
-Diagnosed with depression 3 years ago looking into car windows for what he believes are "govern
agents chasing him due to his enlightenment and knowled
government secrets.” Mr. Callahan states he is feeling
extremely energetic and reports this level of energy for the
past week. States he has not slept for the past four nights
well. He does occasionally use cocaine, but states he has
needed it in the past four days due to his current energy le
Denies any exacerbating or relieving factors. Denies takin
any medications to aid in sleep or lower his energy level.
Mr. Callahan says he currently feels euphoric and extreme
energetic, and he has felt this way for a week. He has not
for four days, but has also not used any substances in fou
days. Mr. Callahan reports frequently having extremely lo
energy and mood, while at other times having extremely h
energy and mood; he reports these changes happening a
couple of times a year, with his last depressive period end
couple months ago after lasting a long time.
Past Medical History -Previous hospitalization 3 years ago from suicide attempt The patient received a diagnosis of depression 3 years ag
following a suicide attempt. The psychiatrist who diagnose
him prescribed him antidepressants (patient cannot recall
name or dose).
No known allergies to food, medication, latex, or environm
allergens
1/
, 1/13/2020 Focused Exam: Bipolar Disorder | In Progress Attempt | Shadow Health
Home Medications -antidepressants (patient doesn't remember name of
No current home medications. Previously was on an
medication and is not currently taking them)
antidepressant (can not recall name or dose), but stopped
to inefficacy and side effects. He reports stopping his regi
without consulting a psychiatrist.
Ask Suicide-
-previous suicide attempt (3 years ago); no longer has suicidal Mr. Callahan reports that his suicide attempt occurred 3 y
Screening (ASQ)
ideations ago but that he doesn’t wish to discuss the details. He den
-previous ideas of wanting to be dead; patient claims no longer having attempted suicide other times or planning to do so
feeling this way and 'love[s] being alive' currently. He reports that during depressive periods, he do
-doesn't believe that other people would be better off without typically experience thoughts of suicide and wanting to be
them dead; however, he is not worried about these thoughts
-no homicidal urges returning, as he feels his depression is behind him.
The patient denies feeling like others would be better off
without him, but he also reports not wanting to delve into t
subject.
He denies ever having experienced homicidal urges.
Mood Disorder
-Patient was previously depressed and says he goes through Mr. Callahan perceives his overall mental health to be
Questionnaire (MDQ)
depressive states a 'couple' times throughout the year exceptional, especially given his feeling that his depressio
-Patient claims they are no longer depressed and currently permanently over. He reports having an exceptionally high
have no suicidal ideations view of himself, enjoying life to the fullest, and not knowin
-Patient is unsure of claims others have not noticed his mood caring about others’ opinions of his mental health.
changes
-'Occasionally' gets into arguments but claims no physical The patient reports irritability that can often culminate in
violence ever arguments but never physical fights.
-Sees self as a 'visionary poet' who will change the world
through his work. He reports typically only sleeping two hours a night.
-Self-concept seems to be overly positive
-Patient moves and talks very quickly Mr. Callahan reports knowing he is typically a very fast tal
-Claims no difficulty in concetrating and mover and says he has racing thoughts. He denies
-Engages in potentially dangerous sexual activity with friends difficulty concentrating on activities that matter to him, suc
and strangers alike writing poetry, at which he has been especially productive
-Spends money on cocaine and on friends past week. In that time frame, he has also had an increas
social activity, libido, and sexual activity.
The patient reports spending most of his money on drugs,
books, and donations to his friends; he admits his parents
express frustration over these spending habits.
https://app.shadowhealth.com/assignment_attempts/5918427 2/
Shadow Health will be performing planned maintenance this Friday, from 7:00am until 7:30am Eastern. During this time (/site_notice_dismissals?from_flash=true&site_noti
assignment attempts will be disabled. Thank you for helping us to improve your Shadow Health experience!
Focused Exam: Bipolar Disorder (Part 2 of 2)
Therapeutic Intervention III - Winter 2020, NUR 304
Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor insight into your learning proces
This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the p
Documentation Review
E D Nursing
ED Nursing Note
Note Mental
Student Response Model Documentation
Status Note SBAR
Chief Complaint Patient was brought in by police due to erratic behavior Lucas Callahan is a 25-year-old man who was brought to
Shadow General Hospital at 11:30 PM; he was taken here
-bouts of depression a 'couple' times of the year policemen who found his behavior erratic. He denies havi
illness or a need to be in the hospital.
History of Present
-Patient reports not sleeping for past 4 days, sleeps only for a Presents to the ED today after being brought in by local la
Illness
'couple of hours' when patient does sleep enforcement. He was found in a grocery store parking lot
-Diagnosed with depression 3 years ago looking into car windows for what he believes are "govern
agents chasing him due to his enlightenment and knowled
government secrets.” Mr. Callahan states he is feeling
extremely energetic and reports this level of energy for the
past week. States he has not slept for the past four nights
well. He does occasionally use cocaine, but states he has
needed it in the past four days due to his current energy le
Denies any exacerbating or relieving factors. Denies takin
any medications to aid in sleep or lower his energy level.
Mr. Callahan says he currently feels euphoric and extreme
energetic, and he has felt this way for a week. He has not
for four days, but has also not used any substances in fou
days. Mr. Callahan reports frequently having extremely lo
energy and mood, while at other times having extremely h
energy and mood; he reports these changes happening a
couple of times a year, with his last depressive period end
couple months ago after lasting a long time.
Past Medical History -Previous hospitalization 3 years ago from suicide attempt The patient received a diagnosis of depression 3 years ag
following a suicide attempt. The psychiatrist who diagnose
him prescribed him antidepressants (patient cannot recall
name or dose).
No known allergies to food, medication, latex, or environm
allergens
1/
, 1/13/2020 Focused Exam: Bipolar Disorder | In Progress Attempt | Shadow Health
Home Medications -antidepressants (patient doesn't remember name of
No current home medications. Previously was on an
medication and is not currently taking them)
antidepressant (can not recall name or dose), but stopped
to inefficacy and side effects. He reports stopping his regi
without consulting a psychiatrist.
Ask Suicide-
-previous suicide attempt (3 years ago); no longer has suicidal Mr. Callahan reports that his suicide attempt occurred 3 y
Screening (ASQ)
ideations ago but that he doesn’t wish to discuss the details. He den
-previous ideas of wanting to be dead; patient claims no longer having attempted suicide other times or planning to do so
feeling this way and 'love[s] being alive' currently. He reports that during depressive periods, he do
-doesn't believe that other people would be better off without typically experience thoughts of suicide and wanting to be
them dead; however, he is not worried about these thoughts
-no homicidal urges returning, as he feels his depression is behind him.
The patient denies feeling like others would be better off
without him, but he also reports not wanting to delve into t
subject.
He denies ever having experienced homicidal urges.
Mood Disorder
-Patient was previously depressed and says he goes through Mr. Callahan perceives his overall mental health to be
Questionnaire (MDQ)
depressive states a 'couple' times throughout the year exceptional, especially given his feeling that his depressio
-Patient claims they are no longer depressed and currently permanently over. He reports having an exceptionally high
have no suicidal ideations view of himself, enjoying life to the fullest, and not knowin
-Patient is unsure of claims others have not noticed his mood caring about others’ opinions of his mental health.
changes
-'Occasionally' gets into arguments but claims no physical The patient reports irritability that can often culminate in
violence ever arguments but never physical fights.
-Sees self as a 'visionary poet' who will change the world
through his work. He reports typically only sleeping two hours a night.
-Self-concept seems to be overly positive
-Patient moves and talks very quickly Mr. Callahan reports knowing he is typically a very fast tal
-Claims no difficulty in concetrating and mover and says he has racing thoughts. He denies
-Engages in potentially dangerous sexual activity with friends difficulty concentrating on activities that matter to him, suc
and strangers alike writing poetry, at which he has been especially productive
-Spends money on cocaine and on friends past week. In that time frame, he has also had an increas
social activity, libido, and sexual activity.
The patient reports spending most of his money on drugs,
books, and donations to his friends; he admits his parents
express frustration over these spending habits.
https://app.shadowhealth.com/assignment_attempts/5918427 2/
