8/31/2018 Focused Exam: Alcohol Abuse | In Progress Attempt | Shadow Health
Focused Exam: Alcohol Abuse (Part 3 of 3)
C487 Psych/Mental Health Clinical - Aug 2018, C487
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Reflections
Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor
insight into your learning process. This reflection activity will help you think more deeply about your performance in the assignment. Use your
documentation as you respond to the prompts at the bottom of the page.
Documentation Review
Nursing Admitting...
Nursing Admitting Note
Mental Status Note Student Response Model Documentation
SBAR
Chief Complaint right wirst pain following a car accident Ms. Adler has a sprained (R) wrist due to an
MVA caused by impaired driving. She is a self-
harm risk and expressed passive suicidal
ideation.
History of involved in a car accident while under the Rachel Adler is a 20-year-old White woman with
Present Illness influence of alcohol, resulted in right wrist a history of alcohol abuse and anxiety. She was
sprain brought to the ER last night by law enforcement
after a MVA in which she was noted to be under
the influence of alcohol and had an injured her
(R) wrist. Assessment in the ER confirmed a
sprain of the (R) wrist, and an alcohol level of
0.2% (over the legal limit in the state for
individuals under the age of 21) was
determined at the scene. Ms. Adler stated she
did not know what happened, but was told she
received a ticket for DUI. Reported pain level
upon arrival to the ER to be 8/10. Pain relief
noted when ibuprofen administered. Ms. Adler
denies any nausea, vomiting. Admitted to adult
mental health unit based on positive
assessment for self harm.
, 8/31/2018 Focused Exam: Alcohol Abuse | In Progress Attempt | Shadow Health
Student Response Model Documentation
Allergies peanuts Peanuts, reaction is itchy mouth and throat
NKDA
Past Medical none, alcohol abuse associated with No medical issues
History overwhelming stress Denies use of prescription or recreational
drugs, denies tobacco use
Past Surgical none No past surgical procedures
History
Medication ibuprofen prn, ortho tri-cyclen lo for birth control Ortho Tri Cyclen Lo, 1 tablet, P.O., daily at 0800
History "Click pack"
Occasional ibuprofen for menstrual cramps
Family History mom had anxiety disorder, grandfather was Mother has anxiety disorder
alcoholic Father has no major medical issues
Maternal grandfather had a history of
alcoholism
Social History full time school, lives with roomate, has no job College student - Junior.
currently, excercizes regulary, inadequate diet Single - sexually active, not in relationship at
drinks 3 to 4 times aweek, four or five drinks at this time. Practices safe sex.
time Tobacco: denies present use of tobacco and
nicotine use.
Alcohol/Illicit Drug Use: denies any illicit drug
use. Uses alcohol at least three times/week.
Reports at least two episodes of passing out
after drinking in the past month.
CAGE Assessment: Ms. Adler doesn't think
others care about her drinking since she mostly
drinks with friends. She drinks to feel better or
feel nothing, does not think this hurts anyone.
No drinking first thing in morning.
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