Focused Exam: Bipolar Disorder | In Progress Attempt | Shadow Health
Focused Exam: Bipolar Disorder (Part 2 of 2)
Therapeutic Intervention III
Reflections
Activity Description: Reflective writing develops your clinic
...
Focused Exam: Bipolar Disorder | In Progress Attempt | Shadow Health
Focused Exam: Bipolar Disorder (Part 2 of 2)
Therapeutic Intervention III
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
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.
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