4/24/2020 Focused Exam: Bipolar Disorder | In Progress Attempt | Shadow Health

SBAR

Student Response Model Documentation

1. Situation Lucas Callahan is a 25-year-old man brought into the ED by

law enforcement aftering behaving erratically in a grocery store

parking lot. He denies any illness.

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.

2. Background Was diagnosed with depression 3 years ago after being

hospitalized for a suicide attempt. Not currently taking

antidepressants. Patient had thoughts of self harm in the past,

but states he does not currently want to due. He denies

thoughts of harming others. He is currently homeless, living in

either his care or with friends. Relationship with parents is

strained due to drug abuse. Patient drinks 4-6 glasses of

alcohol per week with occasional use of coccaine. Reports low

appetite.

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.

3. Assessment Patient exhibits an inflated sense of self, paranoia, insomnia,

poor appetite, racing thoughts, rapidity of speech, increased

irritabilty, with a history of depression and suicidal ideations.

Patient is impulsive. Signs of mood disorder.

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.

4. Recommendation Patient is at risk for self-harm, so should be monitored closely.

Patient is primarily complient, but can become aggiated easily.

Compliance with antidepressant medications should be

emphasized to the patient. Psych consult should be mentioned

to provider.

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.

https://www.qwivy.com/file/60512312/Focused-Exam-Bipolar-Disorder-In-Progress-Attempt-Shadow-Health-SBARpdf/

https://app.shadowhealth.com/assignment_attempts/6730004 1/1

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