Shadow Health Focused Exam: Bipolar Disorder Lucas Callahan
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Course
NUR 4290
Institution
Molloy College
Shadow Health Focused Exam: Bipolar Disorder Lucas Callahan Subjective Data (page 1-27) Education/Empathy (pages 27-28) SBAR (page 28-29) Chief Complaint • Finding: Asked about chief comp laint • Finding: Reports being brought in by police Why are you in the emergency department tonight? Histor...
shadow health focused exam bipolar disorder lucas callahan
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Molloy College
NUR 4290
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Shadow Health Focused Exam: Bipolar
DisorderLucas Callahan
Subjective Data (page 1-27)
Education/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 hurting 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 hallucinations
• Finding:
Denies hallucinations
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 time 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 time 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?
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