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Shadow Health Focused Exam; Lucas Callahan - Bipolar Disorder

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Shadow Health Focused Exam; Lucas Callahan - Bipolar DisorderShadow Health Focused Exam; Lucas Callahan - Bipolar Disorder (Latest 2020). A Graded. 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 ED Nursing Note Student Response Model Documentation Chief Complaint Patient was brought in by police due to erratic behavior -bouts of depression a 'couple' times of the year Lucas Callahan is a 25-year-old man who was brought to Shadow General Hospital at 11:30 PM; he was taken here policemen who found his behavior erratic. He denies havin illness or a need to be in the hospital. History of Present Illness -Patient reports not sleeping for past 4 days, sleeps only for a 'couple of hours' when patient does sleep -Diagnosed with depression 3 years ago Presents to the ED today after being brought in by local la enforcement. He was found in a grocery store parking lot looking into car windows for what he believes are "governm 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 taking 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 low 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

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1


Shadow Health Focused Exam: Bipolar Disorder
Lucas Callahan


Subjec>ve Data (page 1-27)
Educa>on/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 hur>ng 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?

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21 februari 2021
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Aantal pagina's
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Geschreven in
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