Shadow Health Assignments
Bipolar Disorder Lucas Callahan ShadowHealth Documentation
Documentation / Electronic Health Record
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Documentation
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ED Nursing Note
Student Documentation Model Documentation
Chief Complaint
Patient was brought to the hospital by policemen because of strange behavior.
Lucas Callahan, a 25-year-old man, came to Shadow General Hospital at 11:30 PM with policemen. They brought him here because his behavior was unusual. He says he’s not sick and doesn’t need to be in the hospital. Bipolar Disorder Lucas Callahan ShadowHealth Documentation.
History of Present Illness
Lucas Callahan, a 25-year-old man, was brought to the clinic by local law enforcement. They found him in a grocery store parking lot, looking into car windows. He believes government agents are chasing him because he knows government secrets. Bipolar Disorder Lucas Callahan ShadowHealth Documentation.
He came to the ER today with local law enforcement. They found him in a grocery store parking lot, looking into car windows, and he thought government agents were after him because of his knowledge of government secrets. He’s feeling very energetic and has felt this way for the past week. He hasn’t slept for the last four nights. He sometimes uses cocaine, but hasn’t needed it for the past four days because he’s so energized. He doesn’t have any specific things that make this energy worse or better. He hasn’t taken any medications to help him sleep or calm his energy. Bipolar Disorder Lucas Callahan ShadowHealth Documentation.
Review of Systems
General: He’s not tired, hasn’t gained or lost weight, doesn’t have chills or fever. HEENT: He doesn’t have headaches, eye problems, ear problems, nose problems, or throat problems. CV: He doesn’t have chest pain, palpitations, or swollen legs. Gastrointestinal: He’s not nauseous, hasn’t thrown up, and his belly doesn’t hurt. He has bowel movements every 3 days. Skin, hair, nails: He has recent scratches on his back from sex.
General: He’s not tired, doesn’t have a fever, chills, night sweats, swelling, weight changes. HEENT: He doesn’t have headaches, eye problems, ear problems, nosebleeds or congestion, throat issues. Cardiovascular: His heart rate is normal, no chest pain, no leg pain. Skin, hair, and nails: He has scratches on his back from sex. His skin, hair, and nails are otherwise normal. Gastrointestinal: His belly doesn’t hurt, he’s not sick to his stomach, his bowel movements are regular every 3 days. Bipolar Disorder Lucas Callahan ShadowHealth Documentation.
Mental Status Note
Student Documentation Model Documentation
Appearance
He’s bent over, his clothes are dirty, but he’s groomed well. He looks you in the eye.
Mr. Callahan’s posture is hunched over, and his clothes are dirty and messy, but he takes care of his appearance. He makes direct eye contact. Throughout the interview, he’s swaying and fidgeting like he’s full of energy. Bipolar Disorder Lucas Callahan ShadowHealth Documentation.
Attitude
He’s annoyed and avoids some questions.
Mr. Callahan doesn’t trust healthcare professionals much, and he gets annoyed and avoids answering certain questions, especially those about feeling down or thinking about suicide.
Speech
He talks quickly, but at a normal volume, and you can understand him well.
Mr. Callahan talks fast, but not too loud, and he speaks clearly. His rate of speech is fast, but it’s easy to understand him. Bipolar Disorder Lucas Callahan ShadowHealth Documentation.
Bipolar Disorder Lucas Callahan ShadowHealth Documentation
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. |
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 Dont wait until the last minute.Provide your requirements and let our native nursing writers deliver your assignments ASAP. |