Shadow Health Focused Exam: Bipolar Disorder Lucas Callahan

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? 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? • 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? • 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? • Finding: Asked about onset of energy and mood • Finding: Reports high energy began a week ago How long have you been feeling this energetic? • Finding: Reports euphoria began a week ago How long have you been feeling euphoric? Past Medical History • Finding: Asked about existing health conditions • Finding: Reports being diagnosed with depression What existing health conditions do you have? • Finding: Asked about typical moods • Finding: Reports periods of euphoria Do you have periods of feeling really good? • Finding: Reports periods of depression Do you have periods of feeling really bad? • Finding: Asked about typical energy levels • Finding: Reports periods of extremely low energy Do you have periods of low energy? • Finding: Reports periods of extremely high energy Do you have periods of high energy? • Finding: Asked about frequency of mood changes • Finding: Reports mood changes occur a couple of times a year • How many times a year do you experience mood changes? • Finding: Asked about last period of depression • Finding: Reports last depressive period ended a couple months ago When did your last period of depression end? • Finding: Reports last depressive period was a long one • How long was your last period of depression? • Finding: Asked about details of depression diagnosis • Finding: Reports being diagnosed by psychiatrist Who diagnosed you with depression? • Finding: Reports diagnosed 3 years ago When were you diagnosed with depression? • Finding: Asked about reason for seeing psychiatrist • Finding: Reports being made to see the psychiatrist following a suicide attempt What did you see the psychiatrist for? • Finding: Asked about how depression was treated • Finding: Reports psychiatrist prescribed antidepressants Did the psychiatrist prescribe anything for your depression? • Finding: Asked about hospitalizations • Finding: Reports being hospitalized after suicide attempt Were you hospitalized after your suicide attempt? • Finding: Reports being hospitalized 3 years ago When were you hospitalized? • Finding: Asked about allergies • Finding: Denies allergies Do you have any allergies? Home Medications • Finding: Asked about effectiveness of medication • Finding: Reports antidepressants were not effective Were the antidepressants effective? • Finding: Reports antidepressants caused side effects Did the antidepressants cause any side effects? • Finding: Reports stopping the antidepressant regimen Did you continue taking the antidepressants? • Finding: Reports not consulting a healthcare provider before stopping regimen Did you consult your healthcare provider before stopping the antidepressants? • Finding: Followed up on medication side effects • Finding: Reports not wanting to discuss side effects What kind of side effects did the antidepressants cause? • Finding: Followed up on details of the medication prescription • Finding: Denies remembering details of the medication prescription What was the name of the antidepressant? • Finding: Asked about home medications beside antidepressants • Finding: Denies home medications beside antidepressants Do you take any other medications? Ask Suicide Screening Questions • Finding: Followed up on suicide attempt • Finding: Reports attempt occurred 3 years ago When was your suicide attempt? • Finding: Reports not wanting to discuss the suicide attempt How did you attempt suicide? • Finding: Asked about other suicide attempts • Finding: Denies other suicide attempts Have you had other suicide attempts? • Finding: Asked about wanting to be dead • Finding: Denies currently wanting to be dead Do you currently wish you were dead? • Finding: Reports desire to be dead during depressive episodes Have you ever wished you were dead? • Finding: Reports that the desire to be dead is permanently behind him Do you ever wish you were dead? • Finding: Asked about belief that others would be better off without you • Finding: Reports that he does not hold this belief Do you ever think others would be better off without you? • Finding: Reports not wanting to discuss this belief Do you ever think others would be better off without you? • Finding: Asked about thoughts of suicide • Finding: Denies current thoughts of suicide Are you having suicidal thoughts right now? • Finding: Reports previous thoughts of suicide during depressive episodes Have you ever had suicidal thoughts? • Finding: Reports that thoughts of suicide are permanently behind him Do you ever have suicidal thoughts? • Finding: Asked about current plans for suicide • Finding: Denies recent plan to attempt suicide Have you recently planned to commit suicide? • Finding: Reports last suicidal plans were before suicidal attempt 3 years ago Have you ever planned to commit suicide? • Finding: Asked about self-harming without intending to die • Finding: Reports only self-injury was the suicide attempt Have you ever self-harmed? • Finding: Asked about homicidal urges • Finding: Denies homicidal urges Do you ever feel homicidal urges? Mood Disorder Questionnaire • Finding: Asked about perception of mental health • Finding: Reports feeling like his depression is over How do you feel about your depression? • Finding: Reports feeling like mental health is exceptional How would you describe your mental health? • Finding: Reports feeling mental health treatment is unnecessary Do you think you need mental health treatment? • Finding: Asked if others notice mood or energy shifts • Finding: Reports not paying attention to others' perception of him Has anyone commented on your mood and energy shifts? • Finding: Asked about excessive irritability or anger • Finding: Reports feeling angry only when people "interfere with the vibes" When do you get angry or irritable? • Finding: Asked about fights or arguments • Finding: Reports getting into arguments when angry When do you get into arguments? • Finding: Denies getting into physical fights Do you ever get into physical fights? • Finding: Asked about self-concept • Finding: Reports extremely high self-concept What do you think about yourself? • Finding: Asked about typical sleep patterns • Finding: Reports typically sleeping two hours a night How much sleep do you get each night? • Finding: Asked about changes in speed of moving or speaking • Finding: Reports being a very fast speaker and mover Have you noticed changes in how fast you move or speak? • Finding: Asked about racing thoughts • Finding: Reports racing thoughts Do you have racing thoughts? • Finding: Asked about pleasure and interest in typical activities • Finding: Reports very much enjoying life Are you enjoying life right now? • Finding: Asked about ability to concentrate • Finding: Reports extremely high ability to concentrate on what matters How is your ability to concentrate? • Finding: Asked about changes in productivity • Finding: Reports increase in productivity for the past week Have you noticed changes to your productivity? • Finding: Followed up on personal projects • Finding: Reports working on epic poem Tell me more about your personal projects. • Finding: Asked about changes in social activity • Finding: Reports increase in social activity for the past week How has your social life been lately? • Finding: Asked about changes in libido and sexual activity • Finding: Reports increase in libido and sexual activity for the past week Have you noticed any changes to your libido and sexual activity? • Finding: Followed up on details of sexual activity • Finding: Reports having multiple partners How many partners have you been having sex with? • Finding: Reports having sex with friends and strangers Who have you been having sex with? • Finding: Reports having rough sex Are you having rough sex? • Finding: Denies using condoms or contraceptives Do you use condoms? • Finding: Reports having sex with women and men Do you have sex with men or women? • Finding: Denies STI symptoms Do you have any sexually transmitted infections? • Finding: Reports recent STI screening was negative Have you been screened for sexually transmitted infections? • Finding: Asked about spending habits and consequences • Finding: Reports spending money on drugs What do you spend money on? • Finding: Reports shopping often online for rare books What do you spend money on? • Finding: Reports giving money to friends What do you do with your money? • Finding: Reports parents express frustration over his spending habits How do your parents feel about your spending? Social History • Finding: Asked about financial status and occupation • Finding: Denies being employed Are you employed? • Finding: Reports parents give him money Where do you get money? • Finding: Followed up on occupation • Finding: Reports being fired from previous jobs Tell me about your previous jobs. • Finding: Reports not wanting to talk about details of being fired Why were you fired from past jobs? • Finding: Asked about legal troubles • Finding: Denies ever being in trouble with the law Have you been arrested? • Finding: Asked about typical substance use • Finding: Denies tobacco use Do you smoke cigarettes? • Finding: Reports drinking alcohol Do you drink alcohol? • Finding: Reports typical cocaine use Do you use any recreational drugs? • Finding: Denies using recreational drugs besides cocaine Do you use any drugs beside cocaine? • Finding: Followed up on alcohol use • Finding: Reports drinking 2-3 times a week How many times a week do you drink? • Finding: Reports starting to drink at age 18 At what age did you start drinking? • Finding: Reports drinking most when depressed When do you drink? • Finding: Reports drinking to improve mood Does drinking help your mood? • Finding: Reports drinking to aid sleep Does drinking help you sleep? • Finding: Denies alcohol addiction or experiencing withdrawals Do you feel you're addicted to alcohol? • Finding: Denies physical side effects from alcohol use Do you experience any side effects from drinking? • Finding: Followed up on drug use • Finding: Reports using cocaine 2-3 times a week How many times a week do you use cocaine? • Finding: Reports starting using cocaine eight months ago When did you start using cocaine? • Finding: Reports enjoying the boost to mood and energy Why do you use cocaine? • Finding: Denies cocaine addiction or experiencing withdrawals Do you have a dependency on cocaine? • Finding: Denies side effects from cocaine use Do you experience side effects from cocaine? • Finding: Asked about methods of transportation • Finding: Reports getting around via his car Do you drive? • Finding: Denies driving under the influence • Do you ever drive under the influence? • Finding: Denies wearing seatbelt Do you wear a seatbelt? • Finding: Asked about diet and appetite • Finding: Reports eating 1 small meal a day for the past week How many meals do you eat a day? • Finding: Reports typically low appetite How is your appetite? • Finding: Asked about fluid intake • Finding: Reports not keeping track of fluid intake How much water do you drink each day? • Finding: Reports typically drinking wate What do you typically drink? • Finding: Asked about caffeine intake • Finding: Reports not needing caffeine for energy Do you drink caffeine? • Finding: Asked about patient's level of education • Finding: Reports one year of college Did you go to college? • Finding: Reports being expelled from college Did you graduate from college? • Finding: Reports expulsion was due to poor attendance Why were you expelled from college? • Finding: Reports poor attendance was due to depression Why were you expelled from college? • Finding: Asked about access to healthcare • Finding: Reports parents pay for his insurance Do you have health insurance? • Finding: Asked about living situation • Finding: Denies having own residence Where do you live? • Finding: Reports couch-surfing with friends or sleeping in car Where do you stay? • Finding: Reports parents won't house him due to drug use Do you live with your parents? • Finding: Asked about family relationships and support system • Finding: Reports tension with parents over drug use How is your relationship with your parents? • Finding: Reports resentment toward parents for suggesting need for rehab How is your relationship with your parents? • Finding: Reports close relationships with friends How are your relationships with friends? • Finding: Asked about history of abuse • Finding: Denies history of abuse Have you ever experienced abuse? Family Medical History • Finding: Asked about family history of mental illness • Finding: Reports being adopted and not knowing his biological family's history Do you have a family history of mental illness? • Finding: Denies adoptive parents having mental illness Do either of your parents have a mental illness? Review of Systems • Finding: Asked about general symptoms • Finding: Denies fever Do you have a fever? • Finding: Denies chills Are you experiencing chills? • Finding: Denies night sweats Are you experiencing night sweats? • Finding: Denies swelling Are you experiencing swelling? • Finding: Denies weight change Have you experienced any weight changes? • Finding: Asked about review of systems for HEENT • Finding: Denies headaches Do you get headaches? • Finding: Denies eye problems Do you have any eye problems? • Finding: Denies ear problems Do you have any ear problems? • Finding: Denies nosebleeds: Have you experienced nosebleeds? • Finding: Denies congestion Are you congested? • Finding: Denies throat problems Do you have any throat problems? • Finding: Asked about review of systems for cardiovascular • Finding: Denies abnormal heart rate How is your heart rate? • Finding: Denies chest pain Are you experiencing chest pain? • Finding: Denies leg pain Do you have leg pain? • Finding: Asked about review of systems for skin, hair, and nails • Finding: Reports recent scratches on back from sex What are the scratches on your back from? • Finding: Denies other skin changes Have you noticed any other skin changes? • Finding: Denies changes to hair Have there been any changes to your hair? • Finding: Denies changes to nails Have there been any changes to your nails? • Finding: Asked about review of systems for gastrointestinal • Finding: Denies abdominal pain Are you having abdominal pain? • Finding: Denies nausea or vomiting • Are you nauseated? • Finding: Reports bowel movement every three days How often do you have a bowel movement? • Finding: Denies changes to bowel movements Empathy/Education Sleep -inadequate amount of sleep -model statement: "While I understand that you have been experiencing a high amount of energy lately, it's important that you get enough rest. It is recommended that adults receive a minimum of seven hours of sleep per night in order to maintain a healthy lifestyle. Sleep deprivation can have a variety of negative effects on your physical and mental health.” Diet/Hydration -minimal food and fluid intake -model statement: "I understand that you haven't been feeling hungry lately or paying attention to how much water you drink, but it's important that your diet and fluid intake are sufficient. Eating healthy meals and drinking plenty of water are important for fueling your body and mind. Malnutrition and dehydration can lead to serious health problems and exacerbate existing conditions.” Family Tension -tension with his parents -model statement: "I'm sorry to hear of the difficult relationship between you and your parents. That must be tough to deal with, especially since your family has such strong beliefs about your lifestyle.” Fear/Anxiety -agents have been following him -model statement: "I'm sorry that government agents have been following you; that sounds really scary. You're safe here.” Depression/Suicide -reports depression and past suicide attempt -model statement: "I'm sorry you've had to go through all of that. Your experience with depression and suicidal ideation sounds really challenging, and I'm glad you feel fully recovered from the suicide attempt. That couldn't have been easy, but it's clear you've come a long way. I know it wasn't easy to talk about all of that, but I appreciate you sharing that with me." SBAR Situation Lucas Callahan is a 25-year-old white man who was brought to Shadow General Hospital at 11:30 PM by the police for erratic behavior in a grocery store parking lot. He is currently experiencing high energy and euphoria. Background Mr. Callahan’s high energy and euphoria began 1 week ago. He reports not having slept for four days, and that his last substance use was four days ago; his urine drug screening was negative. He has frequently experienced both periods of high energy and euphoria and periods of low energy and depression. He was diagnosed with depression 3 years ago after a suicide attempt by a psychiatrist who prescribed antidepressants. The patient disliked them due to their low efficacy and side effects, and stopped his regimen without consulting his psychiatrist; he does not take other medications. The patient has experienced consistent suicidal ideation during previous depressive periods, but he is not currently suicidal or homicidal. He has no allergies. Assessment Mr. Callahan presented positive for multiple factors consistent with bipolar disorder as determined by the Mood Disorder Questionnaire, including his infrequent sleeping, his low food and fluid intake, his unprotected, rough, and anonymous sexual activity, his frequent alcohol and drug usage, his excessive spending, and his homelessness, all of which he finds to be unproblematic and even ideal behaviors. In response to the Ask Suicide-Screening Questions, he reports previous suicidal ideations but that these are permanently over. Together, these two screenings show the patient is at risk to himself not via direct intentional harm but via dangerous behavioral and lifestyle patterns. Mr. Callahan has a tachycardic heart rate and clear breath sounds, and his ECG and lab results are normal. His back shows recent scratches, and his wrists show healed scars from the previous suicide attempt. His Mental Status Exam showed he screens positive for multiple factors consistent with bipolar disorder, including a disheveled and fidgety appearance, skeptical and evasive attitude, rapid and musical speech, expansive mood with minor shifts to irritability, flight of ideas, delusions and paranoia, limited insight into his condition, and unwillingness to seek treatment. Recommendation My recommendation would be for evaluation by a mental health provider (psych nurse practitioner or psychiatrist) for further evaluation of his symptoms to determine if he meets the criteria for bipolar disorder. His lack of sleep should be addressed as well. His priority nursing care is to keep him safe from injury and increase his knowledge about his current condition. The patient should receive education around bipolar disorder and how its effects can be minimized, especially: treatment compliance, early recognition of mood and energy shifts, ideal nutrition, hydration, and sleep patterns, safe sexual practices, and reduced or eliminated cocaine or alcohol use, potentially via the aid of individual or group counseling, or rehabilitation. I also recommend that the patient should be encouraged to involve his support system in his future education and care. Show Less