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Focused Exam Bipolar Disorder Completed Shadow Health
Mental Health Nursing (NU 309)
Herzing University
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Chief Complaint
History of
Present
Illness
Past Medical
History
Home
Medications
Ask Suicide Screening
Questions
Mood Disorder
Questionnaire
Social History
Family Medical History
Review of
Systems
Asked about chief complaint Reports being brought in by police
Followed up on incident chasing him Reports looking into cars for government agents Reports having been in a grocery store parking lot Reports knowing the police stopped him for running around and looking in cars Denies having hurt himself or others Denies having done anything illegal Followed up on government agents being enlightened Reports government is trying to imprison him for threat to their secrets Reports government sees his enlightenment as a Asked about anxiety or paranoia Denies anxiety or paranoia Reports high awareness of government agents chasing him Asked about hallucinations Denies hallucinations Asked about most recent substance use ago Reports last substance use was about four days Reports last substance use was cocaine Asked about recent sleep history Reports not having slept for four days Asked about current energy levels Reports current extremely high energy Asked about current mood Reports current euphoria Asked about onset of energy and mood Reports high energy began a week ago Reports euphoria began a week ago Asked about existing health conditions Reports being diagnosed with depression Asked about typical moods Reports periods of euphoria Reports periods of depression Asked about typical energy levels Reports periods of extremely low energy Reports periods of extremely high energy Asked about frequency of mood changes year Reports mood changes occur a couple of times a Asked about last period of depression months ago Reports last depressive period ended a couple Reports last depressive period was a long one Asked about details of depression diagnosis Reports being diagnosed by psychiatrist Reports diagnosed 3 years ago Asked about reason for seeing psychiatrist following a suicide attempt Reports being made to see the psychiatrist Asked about how depression was treated Reports psychiatrist prescribed antidepressants Asked about hospitalizations Reports being hospitalized after suicide attempt Reports being hospitalized 3 years ago
Asked about allergies Denies allergies Asked about effectiveness of medication Reports antidepressants were not effective Reports antidepressants caused side effects Reports stopping the antidepressant regimen Reports not consulting a healthcare provider before stopping regimen Followed up on medication side effects Reports not wanting to discuss side effects
prescription Followed up on details of the medication prescription Denies remembering details of the medication
antidepressants Asked about home medications beside Denies home medications beside antidepressants Followed up on suicide attempt Reports attempt occurred 3 years ago Reports not wanting to discuss the suicide attempt Asked about other suicide attempts Denies other suicide attempts Asked about wanting to be dead Denies currently wanting to be dead Reports desire to be dead during depressive episodes Reports that the desire to be dead is permanently behind him
without you Asked about belief that others would be better off Reports that he does not hold this belief Reports not wanting to discuss this belief Asked about thoughts of suicide Denies current thoughts of suicide Reports previous thoughts of suicide during depressive episodes Reports that thoughts of suicide are permanently behind him Asked about current plans for suicide Denies recent plan to attempt suicide Reports last suicidal plans were before suicidal attempt 3 years ago Asked about self-harming without intending to die Reports only self-injury was the suicide attempt Asked about homicidal urges Denies homicidal urges Asked about perception of mental health Reports feeling like his depression is over Reports feeling like mental health is exceptional unnecessary Reports feeling mental health treatment is Asked if others notice mood or energy shifts of him Reports not paying attention to others' perception Asked about excessive irritability or anger with the vibes" Reports feeling angry only when people "interfere Asked about fights or arguments Reports getting into arguments when angry Denies getting into physical fights Asked about self-concept Reports extremely high self-concept Asked about typical sleep patterns Reports typically sleeping two hours a night
speaking Asked about changes in speed of moving or Reports being a very fast speaker and mover Asked about racing thoughts Reports racing thoughts
Asked about fluid intake Reports not keeping track of fluid intake Reports typically drinking water Asked about caffeine intake Reports not needing caffeine for energy Asked about patient's level of education Reports one year of college Reports being expelled from college Reports expulsion was due to poor attendance Reports poor attendance was due to depression Asked about access to healthcare Reports parents pay for his insurance Asked about living situation Denies having own residence Reports couch-surfing with friends or sleeping in car Reports parents won't house him due to drug use
system Asked about family relationships and support Reports tension with parents over drug use Reports resentment toward parents for suggesting need for rehab Reports close relationships with friends Asked about history of abuse Denies history of abuse Asked about family history of mental illness biological family's history Reports being adopted and not knowing his Denies adoptive parents having mental illness Asked about general symptoms Denies fever Denies chills Denies night sweats Denies swelling Denies weight change Asked about review of systems for HEENT Denies headaches Denies eye problems Denies ear problems Denies nosebleeds Denies congestion Denies throat problems Asked about review of systems for cardiovascular Denies abnormal heart rate Denies chest pain Denies leg pain
nails Asked about review of systems for skin, hair, and Reports recent scratches on back from sex Denies other skin changes Denies changes to hair Denies changes to nails
gastrointestinal Asked about review of systems for Denies abdominal pain Denies nausea or vomiting Reports bowel movement every three days Denies changes to bowel movements
Focused Exam Bipolar Disorder Completed Shadow Health
Course: Mental Health Nursing (NU 309)
University: Herzing University
