Bipolar Disorder Lucas Callahan Shadow Health Documentation/Electronic Health Record
ED Nursing Note
| Student Documentation | Model Documentation |
|---|---|
Chief ComplaintPatient brought by policemen due to erratic behavior. |
Lucas Callahan is a 25-year-old man who was brought to Shadow General Hospital at 11:30 PM; he was taken here by policemen who found his behavior erratic. He denies having an illness or a need to be in the hospital Bipolar Disorder Lucas Callahan ShadowHealth Documentation.  Struggling to meet your deadline?Get your assignment on Bipolar Disorder Lucas Callahan Shadow Health Documentation/Electronic Health Record done by certified MDs and PhDs in the USA. ORDER NOW!
Psychotherapy Biological Basis |
History of Present IllnessLucas Callahan is a 25-year old male brought to the clinic by the local law enforcement. He was found in the parking lot of a geocery store looking out of car windows because he believes government agents are chasing him due to his knowledge of government secrets Bipolar Disorder Lucas Callahan ShadowHealth Documentation. |
Presents to the ED today after being brought in by local law enforcement. He was found in a grocery store parking lot looking into car windows for what he believes are “government agents chasing him due to his enlightenment and knowledge of government secrets.” Mr. Callahan states he is feeling extremely energetic and reports this level of energy for the past week. States he has not slept for the past four nights as well. He does occasionally use cocaine, but states he has not needed it in the past four days due to his current energy level. Denies any exacerbating or relieving factors. Denies taking any medications to aid in sleep or lower his energy level Bipolar Disorder Lucas Callahan ShadowHealth Documentation. |
Review of SystemsGeneral: Denies fatigue, weight change, chills, or fever HEENT: DEnies headaches, eye problems, ear problems, nose problems, or throat problems. CV: Denies chest pain, palpitations or edema. Gastrointestinal: Denies nausea, vomiting, or abdominal pain. Bowel movements every 3 days. Skin, hair, nails: Reports recent scratches on back from sex. |
General: Denies fatigue, fever, chills, night sweats, swelling, changes in weight HEENT: Denies headaches, eye problems, ear problems, nose problems including nosebleeds or congestion, and throat problems Cardiovascular: Denies abnormal heart rate, chest pain, leg pain Skin, hair, and nails: Reports recent scratches on back from sex; denies other skin changes; denies changes in hair or nails Gastrointestinal: Denies abdominal pain, nausea or vomiting, or changes to bowel movements; reports bowel movements occur every 3 days |
Mental Status Note
| Student Documentation | Model Documentation |
|---|---|
AppearanceBent posture, dirty clothing, good grooming. Direct eye contact |
Mr. Callahan’s posture is bent and hunched; his clothing is dirty and disheveled, but grooming and self-care are otherwise adequate; his eye contact is direct Bipolar Disorder Lucas Callahan ShadowHealth Documentation. Throughout the interview, he sways and fidgets as if feeling energetic. Bipolar Disorder Lucas Callahan ShadowHealth Documentation |
AttitudeIrritated and evasive toward some questions |
Mr. Callahan displays frequent distrust of healthcare professionals, and becomes irritated and evasive toward certain questions, especially those about depression or suicide. |
SpeechRapid speech rate, appropriate volume, qgood articulation. |
Mr. Callahan’s rate of speech is rapid, but at an appropriate volume, and he has no issues with articulation Bipolar Disorder Lucas Callahan ShadowHealth Documentation |
Bipolar Disorder Lucas Callahan ShadowHealth Documentation
Documentation / Electronic Health Record
Flowsheets
Documentation
ED Nursing Note
Student Documentation Model Documentation
Chief Complaint
The patient was brought to the hospital by the police because of his unusual behavior.
Lucas Callahan, a 25-year-old man, arrived at Shadow General Hospital at 11:30 PM, accompanied by the police due to his erratic behavior. He denies having any illness or the need to be in the hospital.
History of Present Illness
Lucas Callahan, a 25-year-old male, was brought to the clinic by the local law enforcement. He was discovered in the parking lot of a grocery store, looking into car windows, as he believed government agents were chasing him due to his knowledge of government secrets.
He presented to the ED today after being brought in by local law enforcement. He was found in a grocery store parking lot, peering into car windows, believing “government agents are chasing him due to his enlightenment and knowledge of government secrets.” Mr. Callahan mentions feeling extremely energetic and reports this high energy level for the past week. He admits to not having slept for the past four nights. He occasionally uses cocaine but claims he hasn’t needed it in the past four days due to his current energy level. He denies any factors that worsen or improve his condition. He also denies taking any medications to help him sleep or reduce his energy level.
Review of Systems
General: He denies feeling tired, changes in weight, chills, or fever.
HEENT: He denies headaches, eye problems, ear problems, nose problems, or throat problems.
CV: He denies chest pain, palpitations, or swelling.
Gastrointestinal: He denies nausea, vomiting, or abdominal pain. He has a bowel movement every three days.
Skin, hair, nails: He reports recent scratches on his back from sexual activity.
General: He denies fatigue, fever, chills, night sweats, swelling, changes in weight.
HEENT: He denies headaches, eye problems, ear problems, nose problems including nosebleeds or congestion, and throat problems.
Cardiovascular: He denies abnormal heart rate, chest pain, leg pain.
Skin, hair, and nails: Reports recent scratches on his back from sex; denies other skin changes; denies changes in hair or nails.
Gastrointestinal: He denies abdominal pain, nausea or vomiting, or changes to bowel movements; reports bowel movements occur every 3 days.
Mental Status Note
Student Documentation Model Documentation
Appearance
Mr. Callahan exhibits a bent posture and is dressed in dirty clothing, but his grooming is satisfactory. He maintains direct eye contact.
Mr. Callahan’s posture is hunched and he wears disheveled clothing, but his grooming and self-care are otherwise acceptable. He maintains direct eye contact. Throughout the interview, he fidgets and sways, as if full of energy.
Attitude
Mr. Callahan displays irritation and evasiveness towards some questions, especially those related to depression or suicide, showing a general distrust of healthcare professionals.
Speech
He speaks rapidly but at an appropriate volume and has good articulation.
Mr. Callahan speaks rapidly but maintains an appropriate volume and articulation.
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