Focused Exam: Alcohol Abuse (Part 3 of 3) C487 Psych/Mental Health Clinical - Aug 2018, C487

Focused Exam: Alcohol Abuse (Part 3 of 3) C487 Psych/Mental Health Clinical - Aug 2018, C487 Return to Assignment Reflections Documentation Review Nursing Admitting Note Mental Status Note SBAR Student Response Model Documentation 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 Present Illness involved in a car accident while under the influence of alcohol, resulted in right wrist sprain Rachel Adler is a 20-year-old White woman with a history of alcohol abuse and anxiety. She was 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.