Bipolar Disorder Lucas Callahan Shadow Health

Documentation / Electronic Health Record

Patient brought by policemen due to erratic behavior.

Lucas Callahan, a 25-year-old male, was brought to Shadow General Hospital at 11:30 PM by policemen who found his behavior erratic. He denies having an illness or a need to be in the hospital.

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History of Present Illness

Lucas Callahan, a 25-year-old male, was brought to the clinic by local law enforcement. He was found in the parking lot of a grocery store looking into car windows because he believes government agents are chasing him due to his knowledge of government secrets.

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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.

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, 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

Appearance: 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. Throughout the interview, he sways and fidgets as if feeling energetic.

Attitude: Mr. Callahan displays frequent distrust of healthcare professionals and becomes irritated and evasive toward certain questions, especially those about depression or suicide.

Speech: Mr. Callahan’s rate of speech is rapid, but at an appropriate volume, and he has no issues with articulation.

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ED Nursing Note

Student Documentation	Model Documentation
Chief Complaint Patient 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 Illness Lucas 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 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 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
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, 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. Start My Order