Shadow Health Focused Exam: Bipolar
DisorderLucas Callahan
Subjective Data (page 1-27)
Education/Empathy (pages 27-28)
SBAR (page 28-29)
Chief
... [Show More] 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:
Reportslooking into carsfor 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 carsDo
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 governmentsees 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 recentsubstance use
• Finding:
Reportslastsubstance use was about four days ago
When was the last time you used substances?
• Finding:
Reports last substance use was cocaine
Whatsubstance 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? [Show Less]