Shadow Health Anxiety John Larsen

Shadow Health Anxiety John Larsen

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ED Nursing Note

Student Response  Model Documentation
Chief Complaint (No Documentation Made) Mr. Larsen is a 48-year-old White man who presented to the ED at 6 AM with a perceived cardiac complaint; he reports being exhausted, scared and unable to relax from last night.
History of Present Illness (No Documentation Made) Hx of HTN, hyperlipidemia, and osteoarthritis, presented in the ED this morning with complaints of exhaustion, anxiety, terror, and tachycardia which started last night 3 AM. Patient reports that the worry has been around since he was diagnosed with HTN (a year ago), but becomes worse last night. He states that he feels like he is choking, his body is sweating, shivering and he has been unable to control his fear since 3 AM. He says that he is scared about everything, especially his hypertension; he tried to take a deep breath several times to feel calm but did not work. He states that he came to the ED because he thought he was having a heart attack from his hypertension. He says that the anxiety causes him to skip work, prevents social interaction and that it affects his concentration and sleeping patterns. He denies any chest pain, fever, mood changes, or suicidal thoughts.
Allergies (No Documentation Made) Codeine
Past Medical History (No Documentation Made) HTN since age 47 Osteoarthritis since age 46 Hyperlipidemia since age 45
Past Surgical History (No Documentation Made) Total knee replacement age 48
Medication History (No Documentation Made) Atorvastatin 20 mg P.O. daily for high cholesterol. Last dose: yesterday Lisinopril 10 mg P.O. daily for hypertension. Last dose: yesterday Fish oil 1 tab daily for high cholesterol. Last dose: yesterday
Family History (No Documentation Made) Mother, living, high cholesterol Father died of lung cancer, had HTN, deceased age 50 No known family history of mental illness
Social History (No Documentation Made) Employment: Currently employed as a postal clerk. Marital Status: Single, has no children, living alone. Tobacco: He denies past or present tobacco use. Alcohol/Illicit Drug Use: He drinks a beer or two on the weekend, he denies any illicit drug use.
Review of Relevant Systems (No Documentation Made) GENERAL: Fatigue, and diaphoresis. Negative for fever, night sweats, or purposeful changes in weight. RESPIRATORY: Shortness of breath. CARDIOVASCULAR: Palpitations. Negative for chest pain, or edema. NEUROLOGICAL: Reports weakness. Negative for fainting, numbness/tingling, dizziness, frequent headaches, falls, or changes in coordination or memory. PSYCHOLOGICAL: Anxiety, changes in concentration, and sleeping pattern. Denies depression, suicidal thoughts

Mental Status Note

Student Response  Model Documentation
Appearance Good posture, well groomed, and well kept John Larsen is a White, 48 year-old man. He is tall for his sex, and appears overweight. Makes direct eye contact when speaking. Is visibly worried and tense. Posture is stiff. His clothing is appropriate to age, season, setting and occasion. He is not disheveled, and appears well-groomed.
Attitude Cooperative, calm, and open to any questions Mr. Larsen displays a warm and cooperative attitude towards medical staff. Some fear from being in the hospital and moderate anxiety.
Speech within normal limits Mr. Larsen displays no observable issue with articulation, rate, flow, or intensity of volume when he speaks. His vocabulary is appropriate for his age and education level.
Mood and Affect within normal limits, but you can hear the worry in his voice Mr. Larsen’s affect is congruous and appears normal. Mood is currently stable.
Thought Process within normal limits Mr. Larsen’s thoughts appear to be organized and coherent. Thought process is logical, relevant, and follows a normal continuity of thought. Observed no potential for disordered behavior. Observed no rhyming, clang association, or puns.
Thought Content WNL Mr. Larsen displays no sign of homicidal or suicidal ideation. No presence of delusions. No obsessive or intrusive thoughts at the time of the interview. Mr. Larsen does report having experienced excessive worry about his health and his work in the past.
Perceptual Disturbances (No Documentation Made) No observable abnormal perceptions. Mr. Larsen displays no evidence of delusions or hallucinations.
Orientation and Level of Consciousness (No Documentation Made) A&O x 4
Cognition (No Documentation Made) Mr. Larsen is of average general intellect, and his thought is abstract and relevant. His serial 7s are accurate and he is able to comprehend and follow instructions. Displays accurate general knowledge as well as intact remote and immediate memory. Demonstrates new learning ability. He is able to copy the interlocking shapes correctly.
Insight demonstrates awareness of illness and willingness to seek treatment Mr. Larsen displays a partial or unclear awareness of his anxiety, but is beginning to come around to the idea of having anxiety. He shows some willingness to seek treatment.
Judgment demonstrate good judgment Mr. Larsen’s judgement is intact. His response to the “stamped envelope” scenario is appropriate.

SBAR

Student Response  Model Documentation
1. Situation I have pt, John Larsen, 48 year old male, complaints of chest pressure, shortness of breath, diaphoresis, and tachycardia. He is diagnosed for generalized anxiety disorder with panic attack episode Mr. Larsen is 48-year-old White male admitted to the ED today presenting with a panic attack from generalized anxiety disorder.
2. Background Mr. Larson lives alone. His past medical history is having hypertention. H e was diagnosed when he was 47. He’s taking Lisinopril for his high BP. He also have high cholesterol, he taking atrovastatin. He taking fish oils as well. We gave him Prozac here for his anxiety. He’s allergic to codiene Mr. Larsen has a history of HTN, hyperlipidemia, and osteoarthritis. He came to the ER today for a panic attack that is happening for the first time. He was anxious since he was diagnosed with hypertension. The anxiety has been worsening for the last 6 months. He was skipping work, and was fearful at all times. His treatment plans related to this issue to date includes labs, ECG to rule out physical conditions, and anti-anxiety medications.
3. Assessment Patient still feeling smotheres, like having heart attack, pressure on his chest, labored breathing, sweating, tachycardia, muscle tensions. His BP is 125/88, O2 saturation of 99%, RR of 17bpm, heart rate 922 bpm. GAD-7 screening score of 14 (moderate anxiety). Sinus rhythm regular and no ST segment elevation Mr. Larsen was restless and anxious. He has normal ECG readings and lab values except for his glucose and lipids. After he was calmed down, his vitals returned to within normal ranges. The patient has been given Prozac 20 mg orally, and he felt better right after, citing possible placebo effect.
4. Recommendation Needs follow-up meds for his anxiety. Referral to psychotherapy or CBT. Also, some education for his diet. Low-salt diet, and education about the importance of exercise in his life. Based on my assessment, I recommend the following things: • Stay with the patient until he is completely relaxed • Contact provider to schedule an appointment with a psychiatrist as soon as possible • Educate the patient about anxiety and panic disorders • Educate the patient on how to differentiate between physical and psychological symptoms • Educate the patient on relaxation techniques such as deep breathing exercises

 

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