ShadowHealth Mental Health Tina Jones

ShadowHealth Mental Health Tina Jones what brings you in today ans: Reports difficulty sleeping and "feeling nervous" Why did you decide to seek treatment? ans: Reports seeking treatment because she has an upcoming exam and feels "too foggy to study" how do you feel just before bed ans: reports excessive worry and racing thoughts before bed "I'm sorry to hear about your trouble sleeping and stress. I'm glad you came in. Let me learn more about what you're experiencing, and I will try to help." ans: Tina describes problems sleeping and stress-symptoms like racing thoughts. how long have you been having trouble sleeping ans: Reports difficulty sleeping began 3 1/2 weeks ago how long have your sleep difficulties lasted ans: reports sleep difficulties have been occurring regularly past 3.5 weeks how many nights a week do you have trouble sleeping ans: reports difficulty sleeping at least four or five times a week what makes it harder to sleep ans: reports sleeping becomes more difficult when she can not redirect her thoughts from the things she is worried about do you take naps ans: denies naps during the day do you drink caffeine ans: reports drinking caffeine to stay alert when do you usually have your last caffeinated drink ans: reports stopping caffeine use after 4 pm do you drink alcohol before bed ans: denies alcohol use before bed do you use drugs before bed ans: denies drug use before bed do you think your sleep problems could be due to breathing issues ans: reports respiratory problems are controlled and not interfering with sleep what helps you sleep ans: reports sleeping more easily if she can distract herself from her racing thoughts do you exercise ans: reports no exercise how does your lack of sleep affect your daily life ans: reports feeling tired and out of it most of the time during the day due to lack of sleep have you been falling asleep when you didnt mean to ans: reports no increased chance of drifting off during the day despite lack of sleep what do you mean when you say you feel out of it ans: reports feeling slowed down and tired, having trouble focusing, and generally feeling less sharp can you tell me about how your anxiety feels ans: reports feelings of anxiety as thoughts she cant turn off and being on edge do you ever have a sense of impending doom ans: reports worry about the future but no sense of impending doom have you been having panic attacks ans: reports no panic attacks have you been having trouble concentrating ans: reports difficulty concentrating due to fatigue from lack of sleep do you feel restless ans: reports only restlessness occurs just before bed do you feel irritable ans: reports slight irritability due to fatigue how does your anxiety interfere with your daily life ans: reports stress only interferes with daily life because it interrupts her sleep how often do you awaken during the night ans: reports waking up two or three times during the night for at least 10 minutes how do you feel when you wake up in the morning ans: reports waking in the morning feeling out of it and not rested when do you go to bed ans: reports going to bed around midnight but feeling too nervous to sleep when do you fall asleep ans: reports actually falling asleep at 2 or 3 am what do you usually do before bed ans: reports reading before bed do you watch tv or use the computer before bed ans: reports no screen time before bed when do you usually wake up ans: reports average wake time of 8 am how many hours a night do you sleep ans: reports sleeping an average of 4-5 hours a night "It's hard to function at our best when we don't get enough sleep. I know you're very busy with work and school, but let's talk about some strategies to help you get more sleep and make sure you're getting good quality sleep." ans: Tina describes her sleep hygiene and routine. can you describe where you sleep ans: reports sleeping alone in a quiet room how do you feel when you're stressed ans: reports feeling nervous and worrying about the future with racing thoughts are you taking any new medications ans: confirms medications have you been taking OTC meds to help you sleep ans: denies taking OTC sleep meds have you taken prescription medications to help you sleep ans: denies taking prescription sleep medications have you had any new allergies ans: confirms allergies do you have a history of sleep problems ans: reports usually falls asleep very easily and sleeps like a log have you had difficultly falling asleep before ans: reports only past sleep problems occurred for a few months after dad died have you ever had depression ans: denies history of depression have you ever had anxiety ans: denies history of anxiety do you have a psychiatric illness ans: denies current psychiatric illness do you have a history of psychiatric illness ans: denies history of psychiatric illness denies past psychiatric treatment do you have bipolar disorder ans: denies bipolar disorder do you have schizophrenia ans: denies schizophrenia do you have OCD ans: denies OCD have you taken psychotropic meds ans: denies psychotropic meds do you have symptoms of depression ans: reports belief she does not have depression symptoms do you have difficulty making decisions ans: reports no difficultly making decisions have you had less energy than usual ans: reports slightly decreased energy due to lack of sleep do you feel guilty for no reason ans: denies feelings of guilt or worthlessness do you feel hopeless ans: denies feelings of hopelessness have you had trouble enjoying your usual activities ans: denies loss of enjoyment in activities usually found enjoyable have you had a change in appetite ans: reports slightly less appetite because she feels queasy from lack of sleep do you feel sad ans: denies feelings of sadness have you ever had suicidal thoughts ans: denies suicidal thoughts have you ever done something that could end your life ans: denies suicidal behaviors have you ever attempted suicide in the past ans: denies suicide attempts have you ever hurt yourself ans: denies self harm have you experienced any trauma ans: denies past trauma do you have angry outbursts ans: denies angry outbursts have you had a history of violent behavior ans: denies past violent behavior have you ever tried to harm others ans: denies desire to harm others are you employed ans: currently employed where do you work ans: works for a shipping company how many hours a week do you work ans: works 32 hours a week how much work do you miss ans: rarely misses work "It sounds like you have a lot on your plate. I'm sorry you're dealing with so much stress." ans: Tina describes how busy she is with school and work what is your highest level of education ans: about to receive BA in accounting have you ever taken special education courses ans: denies past special education courses do you have any learning disablities ans: denies learning disabilities do you have any speech problems ans: denies speech problems do you have hearing problems ans: denies hearing problems what do you do for fun ans: hobbies are reading and watching TV do you have a legal history ans: denies past legal issues have you served in the military ans: denies military service can you tell me about your housing ans: lives in a house do you live with anyone ans: lives a home with mom and sister do you have siblings ans: brother and sister can you tell me about your family ans: dad died in MVA almost 2 years ago does your family get along well ans: reports family is tight knit and gets along well who are your friends ans: close group of friends from middle and high school as well as from church how often do you spend time with friends ans: spends time with friends a few times a month though less so with her recent schedule what are your religious beliefs ans: identifies as baptist do you attend church regularly ans: attending baptist church regularly since childhood have you ever used drugs ans: smoked pot in high school do you currently use drugs ans: denies current substance use how long did you smoke pot ans: reports smoking marijuana for 5 or 6 years when did you last smoke pot ans: last smoked pot when she was 20 or 21 why did you stop smoking pot ans: it wasnt fun anymore and bad for asthma why did you smoke pot ans: for recreation do you drink alcohol ans: confirms alcohol use how often do you drink alcohol ans: couple times a month how much alcohol do you drink ans: few drinks when she goes out how many drinks per month ans: 10-12 drinks per month why do you drink alcohol ans: to relax and blow off steam has anyone asked you to stop drinking ans: denies anyone has asked her to stop drinking do you feel guilty after you drink ans: denies guilt associated with drinking do you drink and drive ans: takes a cab home do you use tobacco ans: denies use of tobacco have you ever used tobacco ans: denies use of tobacco do you use take medications that are not prescribed to you ans: denies prescription drug abuse are you in a relationship ans: single have you been in a relationship in the past ans: past relationship when was your last relationship ans: ended 3 years ago how long was your last relationship ans: lasted 3 years have you ever been married ans: never been married have you had sex in the past ans: past sexual relationships how many sexual partners have you had ans: 3 previous partners when did you last have sex ans: with boyfriend 3 years ago do you have a history of abuse ans: denies abuse have you ever been physically abused ans: denies physical abuse have you ever been verbally abused ans: denies verbal abuse what stresses you out ans: feeling stressed about studying and the future what tests are you studying for ans: CPA in one month what about the future stresses you out ans: upcoming graduation from college and needing to find a job how do you cope with stress ans: going to church staying organized talking to friends and family "It sounds like you have healthy support systems through your family and friends, which is great. It sounds like you work hard to manage your time effectively, too. Remember to take time out to relax or take a walk." ans: Tina describes her coping mechanisms and support systems. do your coping strategies help your stress ans: coping strategies are less effective has anyone in your family had a history of psychiatric illness ans: denies psychiatric illness in the family does anyone in your family have a history of alcohol dependency ans: uncle is an alcoholic does you family have a history of drug addiction ans: denies family history of drug addiction has anyone in your family committed suicide ans: denies family history of suicide subjective documentation ans: HPI: Ms. Jones presents to the clinic complaining of difficulty sleeping which she notes to have started 1 month ago. She states that her sleep is "shallow and not restful". She complains of difficulty falling asleep at least 4 or 5 nights per week, but states that she is able to stay asleep without difficulty. On average she sleeps 4 or 5 hours per night and awakens at 8:00am daily. She states that she has a fairly consistent schedule on weekdays and weekends. She does not take any prescription or over the counter sleep aids. She limits screen time prior to bed and does not ingest caffeine after 4pm daily. She endorses decreased feelings of sleepiness over the past month. She denies difficulties awaking, but does not feel rested in the morning and has daytime fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity). She does not take naps. Social History: She states that she has some stress related to her upcoming examinations and her impending job search upon graduation. She states that she has a strong support system made up of friends and family and she is active in her church. She states that she copes with stress by staying organized. She enjoys reading and watching television (1-2 hours per day). She states that her father died in a car accident a year and a half ago, which was difficult for her and she experienced some difficulties with sleep at that time as well. She denies use of tobacco. She drinks approximately 10-12 alcoholic beverages per month, but never more than 3 per sitting and does not note any impact on her sleep. She has used marijuana in the past, but no current use and denies other illicit drugs. She does not exercise regularly, but states that her job is somewhat active and she walks 5-15 minutes daily. She drinks 1-3 diet colas per day. Family History: Denies any history of known sleep disorders or psychiatric disorders. Review of Systems: • General: Denies changes in weight, weakness, fever, chills, and night sweats. Does complain of increasing daytime fatigue. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Endorses changes in concentration and sleep. Denies changes or difficulties in coordination. • Psychiatric: States that her mood has been "off" and she does not feel like herself. She does complain of increased anxiety related to upcoming exams and job search. She has no history of depression, but does state that she feels helpless and notes that her performance at work and school is beginning to decline. She denies tension or memory loss. No past suicide attempts. Denies suicidal or homicidal ideation. assessment ans: sleep disturbances related to anxiety plan ans: • Encourage Ms. Jones to continue to monitor symptoms and log her episodes of insomnia and anxiety with associated factors and bring log to next visit. • Encourage to decrease caffeine consumption and increase intake of water and other fluids. • Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery. Continue to monitor and explore the need for possible referral to social work/psychiatry or pharmacologic intervention. • Discuss need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2pm, limiting fluids after dinner, limiting screen time or stimulating activities after 8pm, and to get out of bed if awaken in the middle of the night. • Educate to limit alcohol and depressant medications (including diphenhydramine and Tylenol PM). • Educate on when to seek further or emergent care including feelings of self-harm or hopelessness. • Revisit clinic in 2-4 weeks for follow up and evaluation