Subjective Data (page 1-27) Education/Empathy (pages 27-28) SBAR (page 28-29) Chief Complaint • Finding: Asked about chief complaint • 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? lOMoARcPSD|12263423 2 Downloaded by Anna Maina (annamurugijoe@gmail.com) • 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? lOMoARcPSD|12263423 3 Downloaded by Anna Maina (annamurugijoe@gmail.com) • 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? lOMoARcPSD|12263423 4 Downloaded by Anna Maina (annamurugijoe@gmail.com) • 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