Focused Exam: Bipolar Disorder | In Progress Attempt | Shadow Health

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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. [Show More]

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