Bipolar Disorder Lucas Callahan ShadowHealth Documentation
Lucas Callahan, a 25-year-old man, was taken to Shadow General Hospital around 11:30 PM by the police because they found his behavior strange. He claims he’s not sick and doesn’t need to be in the hospital.
Lucas Callahan, a 25-year-old man, was brought to the clinic by the police. They found him in a grocery store parking lot, peeking into car windows because he believes government agents are chasing him for knowing secrets.
He came to the emergency department escorted by the police, after being discovered in a grocery store parking lot peering into cars, convinced that government agents are pursuing him due to his supposed knowledge of classified information. He mentions feeling excessively energetic for the past week and not sleeping for four nights. He admits to occasional cocaine use but says he hasn’t needed it recently due to his heightened energy levels. He denies taking any medication to help him sleep or lower his energy.
He was brought in by the police after they found him behaving oddly in a grocery store parking lot. He thinks government agents are after him because he knows things he shouldn’t. He says he’s been full of energy for a week and hasn’t slept for four nights, though he admits to using cocaine occasionally. However, he claims he hasn’t needed it lately because of his high energy levels.
He denies feeling tired, having a fever, experiencing chills, or gaining or losing weight. He also denies having headaches, eye, ear, nose, or throat problems. He reports no chest pain, irregular heartbeats, or swelling. His bowel movements occur every three days, and he mentions recent scratches on his back from sexual activity.
He denies fatigue, fever, chills, night sweats, swelling, changes in weight. He also denies headaches, eye, ear, nose problems including nosebleeds or congestion, and throat problems. He reports no chest pain, abnormal heart rate, or leg pain. He mentions recent scratches on his back from sex and says he hasn’t had any other skin, hair, or nail changes. He denies abdominal pain, nausea, vomiting, or changes in bowel movements, noting they occur every three days.
Lucas Callahan has a hunched posture, wears dirty clothes, but his grooming is decent. He maintains direct eye contact during conversation. Throughout the interview, he appears restless and energetic.
Mr. Callahan’s posture is bent, his clothes are dirty, but he maintains good grooming. He looks directly at the interviewer. Throughout the conversation, he seems fidgety, as if full of energy.
He seems irritated and avoids answering some questions.
He often seems distrustful of healthcare workers and gets annoyed and avoids answering certain questions, especially those about depression or suicide.
He speaks quickly, but you can understand him well.
He talks fast, but you can understand him clearly.
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 |
