Focused Exam Bipolar Disorder Completed Shadow Health PDF

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oBJECTIVE DATA FOR DCE MENTAL HEALTH...

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5/26/2021

Focused Exam: Bipolar Disorder | Completed | Shadow Health

Chief Complaint Asked about chief complaint

Reports being brought in by police

History of Present

Illness Followed up on incident

Reports looking into cars for government agents chasing him 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

Past Medical History Home Medications

Followed up on government agents

Reports government is trying to imprison him for being enlightened Reports government sees his enlightenment as a threat to their secrets

Ask Suicide Screening Questions

Asked about anxiety or paranoia

Denies anxiety or paranoia Reports high awareness of government agents chasing him

Mood Disorder Questionnaire

Asked about hallucinations

Asked about most recent substance use

Denies hallucinations

Reports last substance use was about four days ago Reports last substance use was cocaine

Social History Family Medical History Review of

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

Reports mood changes occur a couple of times a year

Asked about last period of depression

Reports last depressive period ended a couple months ago Reports last depressive period was a long one

Asked about details of depression diagnosis

Asked about reason for seeing psychiatrist

Systems

Reports being diagnosed by psychiatrist Reports diagnosed 3 years ago

Reports being made to see the psychiatrist following a suicide attempt

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

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5/26/2021

Focused Exam: Bipolar Disorder | Completed | Shadow Health Asked about allergies

Asked about effectiveness of medication

Followed up on medication side effects

Followed up on details of the medication prescription

Asked about home medications beside antidepressants

Denies allergies

Reports antidepressants were not effective Reports antidepressants caused side effects Reports stopping the antidepressant regimen Reports not consulting a healthcare provider before stopping regimen

Reports not wanting to discuss side effects

Denies remembering details of the medication prescription

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

Asked about belief that others would be better off without you

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

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 Reports feeling mental health treatment is unnecessary

Asked if others notice mood or energy shifts

Reports not paying attention to others' perception of him

Asked about excessive irritability or anger

Reports feeling angry only when people "interfere with the vibes"

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

Asked about changes in speed of moving or speaking

Asked about racing thoughts

Reports being a very fast speaker and mover

Reports racing thoughts

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5/26/2021

Focused Exam: Bipolar Disorder | Completed | Shadow Health

Asked about pleasure and interest in typical activities

Asked about ability to concentrate

Reports very much enjoying life

Reports extremely high ability to concentrate on what matters

Asked about changes in productivity

Reports increase in productivity for the past week

Followed up on personal projects

Reports working on epic poem

Asked about changes in social activity

Reports increase in social activity for the past week

Asked about changes in libido and sexual activity

Reports increase in libido and sexual activity for the past week

Followed up on details of sexual activity

Asked about spending habits and consequences

Asked about financial status and occupation

Followed up on occupation

Reports having multiple partners Reports having sex with friends and strangers Reports having rough sex Denies using condoms or contraceptives Reports having sex with women and men Denies STI symptoms Reports recent STI screening was negative

Reports spending money on drugs Reports shopping often online for rare books Reports giving money to friends Reports parents express frustration over his spending habits

Denies being employed Reports parents give him money

Reports being fired from previous jobs Reports not wanting to talk about details of being fired

Asked about legal troubles

Denies ever being in trouble with the law

Asked about typical substance use

Denies tobacco use Reports drinking alcohol Reports typical cocaine use Denies using recreational drugs besides cocaine

Followed up on alcohol use

Reports drinking 2-3 times a week Reports starting to drink at age 18 Reports drinking most when depressed Reports drinking to improve mood Reports drinking to aid sleep Denies alcohol addiction or experiencing withdrawals Denies physical side effects from alcohol use

Followed up on drug use

Reports using cocaine 2-3 times a week Reports starting using cocaine eight months ago Reports enjoying the boost to mood and energy Denies cocaine addiction or experiencing withdrawals Denies side effects from cocaine use

Asked about methods of transportation

Asked about diet and appetite

Reports getting around via his car Denies driving under the influence Denies wearing seatbelt

Reports eating 1 small meal a day for the past week Reports typically low appetite

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5/26/2021

Focused Exam: Bipolar Disorder | Completed | Shadow Health 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

Asked about family relationships and support system

Asked about history of abuse

Asked about family history of mental illness

Denies having own residence Reports couch-surfing with friends or sleeping in car Reports parents won't house him due to drug use

Reports tension with parents over drug use Reports resentment toward parents for suggesting need for rehab Reports close relationships with friends

Denies history of abuse

Reports being adopted and not knowing his biological family's history 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

Asked about review of systems for skin, hair, and nails

Reports recent scratches on back from sex Denies other skin changes Denies changes to hair Denies changes to nails

Asked about review of systems for gastrointestinal

Denies abdominal pain Denies nausea or vomiting Reports bowel movement every three days Denies changes to bowel movements

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