Lucas Callahan Shadow Health: Bipolar Disorder

Documentation / Electronic Health Record

ED Nursing Note
Chief Complaint

Mr. Lucas Callahan was brought to Shadow General Hospital by policemen at 11:30 PM due to his erratic behavior. He denies having any illness or need to be in the hospital.

History of Present Illness

Lucas Callahan, a 25-year-old male, arrived at the clinic with the assistance of local law enforcement. He was found in a grocery store parking lot, exhibiting unusual behavior, and claiming that government agents are pursuing him because of his knowledge of government secrets.

Review of Systems

General: He denies fatigue, 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 edema.
Gastrointestinal: He denies nausea, vomiting, or abdominal pain. Bowel movements occur every 3 days.
Skin, hair, nails: He reports recent scratches on his back from sexual activity.

Mental Status Note

Student Documentation Model Documentation

Appearance

Mr. Callahan displays a bent posture, wearing dirty clothing, but his grooming is good. He maintains direct eye contact. Throughout the interview, he appears energetic, swaying and fidgeting.

Attitude

Mr. Callahan frequently shows distrust towards healthcare professionals, becoming irritated and evasive, particularly when asked about depression or suicide.

Speech

Mr. Callahan speaks at a rapid rate, but with an appropriate volume and clear articulation.

Bipolar Disorder Lucas Callahan ShadowHealth Documentation

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.

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

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