Alcohol Use Disorder Rachel Adler shadow health Documentation/Electronic Health Record
Chief Complaint:
Ms. Adler has a sprained right wrist due to a car accident caused by her driving while under the influence of alcohol (DUI). She is at risk for self-harm and has expressed passive thoughts about wanting to die.
History of Present Illness:
Rachel Adler is a 20-year-old White woman with a history of alcohol use disorder (AUD) and anxiety. She was brought to the emergency room (ER) last night by law enforcement after a motor vehicle accident (MVA) where she was driving under the influence of alcohol and injured her wrist.
Rachel Adler is a 20-year-old White female with a history of alcohol use and anxiety. She was brought to the ER last night by law enforcement after a MVA in which she was noted to be under the influence of alcohol and had injured her right wrist. Assessment in the ER confirmed a sprain of the right wrist, and an alcohol level of 0.2% (over the legal limit in the state for individuals under the age of 21) was determined at the scene.
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Ms. Adler stated she did not know what happened, but was told she received a ticket for DUI. Reported pain level upon arrival to the ER was 8 out of 10. Pain relief was noted when ibuprofen was administered. Ms. Adler denies any nausea or vomiting. She was admitted to the adult mental health unit based on a positive assessment for self-harm risk due to her alcohol use disorder.
Allergies
Peanut allergy, NKDA
Peanut allergy with symptoms of an itchy mouth and throat. No known drug allergies (NKDA).
Past Medical History
No medical issues
No medical issues; she denies the use of recreational drugs and denies tobacco use.
Past Surgical History
No past surgeries.
No past surgical procedures.
Medication History
Ibuprofen, Ortho Tri Cyclen Lo, 1 tablet daily
Ortho Tri Cyclen Lo, one tablet, P.O., daily at 0800. Occasional ibuprofen for menstrual cramps.
Family History
Father: No health issues, Mother: Anxiety disorder, Maternal grandfather: Alcoholism
Mother has anxiety disorder, father has no major medical issues, and maternal grandfather had a history of alcoholism.
Social History
Junior college student. Single, not sexually active. Denies tobacco and illicit drugs use; uses alcohol at least three times a week.
College student – Junior. Single – sexually active, not in a relationship at this time. Practices safe sex. Tobacco: denies present use of tobacco and nicotine use. Alcohol/Illicit Drug Use: denies any illicit drug use. Uses alcohol at least three times a week, which raises concerns related to her alcohol use disorder.
Thought Content
Passive suicidal ideation
Ms. Adler displays passive suicidal ideation and expresses that she does not care if she lives or dies. She does not express any active suicidal ideation or plans for ending her life. She says she has never attempted suicide or planned a suicide attempt. Ms. Adler seems to be under stress from school and her relationship with her mother. She is deeply distraught over her DUI and the circumstances that brought her to the ER.
Perceptual Disturbances
No delusions or abnormal tendencies
Ms. Adler displays no evidence of delusions or observable abnormal tendencies during the exam. There is no evidence of hallucinations or false sensory perceptions.
Conclusion
This case illustrates the complexities of alcohol use disorder (AUD) and highlights the importance of mental health assessments in individuals with a history of substance use. Understanding the interplay between AUD, mental health, and emergency care documentation is crucial for effective treatment and support.
Alcohol Use Disorder Rachel Adler shadow health Documentation/Electronic Health Record
Nursing Admitting Note
| Student Documentation | Model Documentation |
|---|---|
Chief ComplaintSprained wrist due to a car accident caused by drinking under the influence of alcohol. |
Ms. Adler has a sprained (R) wrist due to an MVA caused by impaired driving. She is a self-harm risk and expressed passive suicidal ideation. |
History of Present IllnessRachel Adler isa 20-year old White female with a history of alcohol use and anxiety. She was brought by law enforcement after a moving vehicle accident in which she was driving under the influence of alcohol and injured her wrist. |
Rachel Adler is a 20-year-old White woman with a history of alcohol use and anxiety. She was brought to the ER last night by law enforcement after a MVA in which she was noted to be under the influence of alcohol and had an injured her (R) wrist. Assessment in the ER confirmed a sprain of the (R) wrist, and an alcohol level of 0.2% (over the legal limit in the state for individuals under the age of 21) was determined at the scene. Ms. Adler stated she did not know what happened, but was told she received a ticket for DUI. Reported pain level upon arrival to the ER to be 8/10. Pain relief noted when ibuprofen administered. Ms. Adler denies any nausea, vomiting. Admitted to adult mental health unit based on positive assessment for self harm. Alcohol Use Disorder Rachel Adler shadow health Documentation |
AllergiesPeanut allergy NKDA |
Peanuts, reaction is itchy mouth and throat NKDA |
Past Medical HistoryNo medical issues Alcohol Use Disorder Rachel Adler shadow health Documentation |
No medical issues Denies use of recreational drugs, denies tobacco use |
Past Surgical HistoryNo past surgeries. |
No past surgical procedures |
Medication HistoryIbuprofen Ortho Tri Cyclen Lo, 1 tablet daily |
Ortho Tri Cyclen Lo, 1 tablet, P.O., daily at 0800 “Click pack” Occasional ibuprofen for menstrual cramps |
Family HistoryFather: No health issues Mother: anxiety disorder Maternal grandfather: alcoholism |
Mother has anxiety disorder Father has no major medical issues Maternal grandfather had a history of alcoholism |
Social HistoryJunior college student. Single, not sexually active. Denies tobacco and illicit drugs use Uses alcohol at least 3 times a week. |
College student – Junior. Single – sexually active, not in relationship at this time. Practices safe sex. Tobacco: denies present use of tobacco and nicotine use. Alcohol/Illicit Drug Use: denies any illicit drug use. Uses alcohol at Alcohol Use Disorder Rachel Adler shadow health Documentation |
Thought ContentPassive suicidal ideation |
Ms. Adler displays passive suicidal ideation and expresses that she does not care if she lives or dies. Ms. Adler does not express any active suicidal ideation or plans for ending her life. She says she has never attempted suicide or planned a suicide attempt. Ms. Adler seems to be under stress from school and her relationship with her mother. She is deeply distraught over her DUI and the circumstances that brought her to the ER. |
Perceptual DisturbancesNo delusions or abnormal tendencies |
Ms. Adler displays no evidence of delusions or observable abnormal tendencies during the exam. There is no evidence of hallucinations or false sensory perceptions. Alcohol Use Disorder Rachel Adler shadow health Documentation |
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