Bipolar Disorder Lucas Callahan Shadow Health Documentation

Bipolar Disorder Lucas Callahan Shadow Health Documentation

Documentation / Electronic Health Record

ED Nursing Note

Student Documentation Model Documentation

Chief Complaint

The patient was 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 for Bipolar Disorder Lucas Callahan ShadowHealth Documentation.

History of Present Illness

Lucas Callahan is a 25-year-old male brought to the clinic by local law enforcement. He was found in the parking lot of a grocery 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 Systems

General: 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 the back from sex.

General: Denies fatigue, fever, chills, night sweats, swelling, and 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 the 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

Appearance

Bent 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

Attitude

Irritated 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.

Speech

Rapid speech rate, appropriate volume, and good 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

Also check: Pathophysiology And Facilitative Communication And Helping Skills

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