Shadow Health Anxiety John Larsen

ED Nursing Note
Student Response  Model Documentation

Chief Complaint (No Documentation Mr. Larsen is a 48-year-old White man who presented to the ED at 6 AM with a
Made) perceived cardiac complaint; he reports being exhausted, scared and unable to
relax from last night.

History of (No Documentation Hx of HTN, hyperlipidemia, and osteoarthritis, presented in the ED this
Present Illness Made) 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 Codeine

Made)

Past Medical (No Documentation HTN since age 47 Osteoarthritis since age 46 Hyperlipidemia since age 45
History Made)

Past Surgical (No Documentation Total knee replacement age 48

History Made)

Medication (No Documentation Atorvastatin 20 mg P.O. daily for high cholesterol. Last dose: yesterday
History Made) 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 Mother, living, high cholesterol Father died of lung cancer, had HTN, deceased
Made) age 50 No known family history of mental illness

Social History (No Documentation Employment: Currently employed as a postal clerk. Marital Status: Single, has
Made) 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 (No Documentation GENERAL: Fatigue, and diaphoresis. Negative for fever, night sweats, or
Relevant Systems Made) purposeful changes in weight. RESPIRATORY: Shortness of breath.
 Student Response  Model Documentation

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, John Larsen is a White, 48 year-old man. He is tall for his sex, and appears
well groomed, overweight. Makes direct eye contact when speaking. Is visibly worried and tense.
and well kept Posture is stiff. His clothing is appropriate to age, season, setting and occasion. He
is not disheveled, and appears well-groomed.

Attitude Cooperative, Mr. Larsen displays a warm and cooperative attitude towards medical staff. Some
calm, and open fear from being in the hospital and moderate anxiety.
to any questions

Speech within normal Mr. Larsen displays no observable issue with articulation, rate, flow, or intensity of
limits volume when he speaks. His vocabulary is appropriate for his age and education
level.

Mood and within normal Mr. Larsen's affect is congruous and appears normal. Mood is currently stable.
Affect limits, but you
can hear the
worry in his
voice

Thought Process within normal Mr. Larsen's thoughts appear to be organized and coherent. Thought process is
limits 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 (No No observable abnormal perceptions. Mr. Larsen displays no evidence of delusions or
Disturbances Documentation hallucinations.
Made)

Orientation and (No A&O x 4

Level of Documentation
 Student Response  Model Documentation

Consciousness Made)

Cognition (No Mr. Larsen is of average general intellect, and his thought is abstract and relevant.
Documentation His serial 7s are accurate and he is able to comprehend and follow instructions.
Made) 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 Mr. Larsen displays a partial or unclear awareness of his anxiety, but is beginning
awareness of to come around to the idea of having anxiety. He shows some willingness to seek
illness and treatment.
willingness to
seek treatment

Judgment demonstrate Mr. Larsen's judgement is intact. His response to the "stamped envelope" scenario is appropria
good judgment

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
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
 Student Response
ST segment elevation
4. Needs follow-up meds for his anxiety. Referral to
Recommendation pscyhotherapy or CBT. Also, some education for
his diet. Low-salt diet, and education about the
importance of exercise in his life.
 Model Documentation
after, citing possible placebo effect.
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