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Mental Health subjective and Completed Transcript Shadow Health

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Mental Health subjective and Completed Transcript Shadow Health

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Mental Health
subjective and
Completed
Transcript
Shadow Health

,10/5/2020 Mental Health | Completed | Shadow Health

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Mental Health Results | Turned In
Advanced Health Assessment - July 2020, NURP 500/530
Return to Assignment (/assignments/356682/)




Your Results Reopen (/assignment_attempts/8022602/reopen)

Lab Pass (/assignment_attempts/8022602/lab_pass.pd




Overview
Subjective Data Collection: 44 of 44 (100.0%)




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Transcript




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Subjective Data Collection




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Hover To Reveal... Indicates an item that you
Objective Data Collection found.




o.
Hover over the Patient Data items Indicates an item that is
Education & Empathy

rs e below to reveal important
information, including Pro Tips and
available to be found.
ou urc
Documentation
Example Questions.
o

Category Scored Items Patient Data
aC s

Not Scored
vi y re


Experts selected these topics as essential components A combination of open and closed questions will yield
of a strong, thorough interview with this patient. better patient data. The following details are facts of t
patient's case.
ed d




Chief Complaint
ar stu




Established chief complaint Reports difficulty sleeping and "feeling nervous"
Reports seeking treatment because she has an
upcoming exam and feels "too foggy to study"
is




Reports excessive worry and "racing thoughts"
before bed
Th




History of Present Illness
sh




Asked about onset and duration of symptoms Reports difficulty sleeping began 3 1/2 weeks ago
Reports sleep difficulties have been occurring
regularly during past 3 1/2 weeks



Asked about frequency of symptoms Reports difficulty sleeping at least four or five
times a week



Asked about aggravating factors Reports sleeping becomes more difficult when
Support
she can not redirect her thoughts from the things
she is worried about
This study source was downloaded by 100000822899794 from CourseHero.com on 04-20-2021 12:17:53 GMT -05:00

https://app.shadowhealth.com/assignment_attempts/8022602 1/6
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, 10/5/2020 Mental Health | Completed | Shadow Health
Denies naps during the day
Reports drinking caffeine to stay alert
Reports stopping caffeine use after 4 P.M.
Denies alcohol use before bed
Denies drug use before bed
Reports respiratory problems are controlled and
not interfering with sleep



Asked about relieving factors Reports sleeping more easily if she can distract
herself from her "racing thoughts"
Reports no exercise



Asked about impact of sleeping problems on Reports feeling tired and "out of it" most of the
daily living time during the day due to lack of sleep
Reports no increased chance of drifting off during
the day despite lack of sleep



Followed up about patient's experience feeling Reports feeling slowed down and tired, having
"out of it" trouble focusing, and generally feeling "less sharp"




m
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Asked about anxiety symptoms Reports feelings of anxiety as "thoughts she can't
turn off" and "being on edge"




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Reports worry about the future, but no sense of




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impending doom
Reports no panic attacks




o.
Reports difficulty concentrating due to fatigue

rs e from lack of sleep
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Reports only restlessness occurs just before bed
Reports slight irritability due to fatigue
o

Asked about impact of anxiety on daily living Reports stress only interferes with daily life
because it interrupts her sleep
aC s


Reports stress does not prevent her from
vi y re


completing her usual activities



Asked about sleep quality Reports falling asleep often takes more than an
ed d




hour
Reports waking up two or three times during the
ar stu




night for "at least ten minutes"
Reports waking in the morning feeling "out of it"
and not rested
is




Asked about sleep habits Reports going to bed "around midnight," but
Th




feeling "too nervous" to sleep
Reports actually falling asleep at 2 or 3 AM
Reports reading before bed
Reports no screen use (television or computer)
before bed
sh




Reports average wake time of 8 AM
Reports sleeping an average of 4 or 5 hours a
night
Reports sleeping alone in a quiet room



Asked about stress quality Reports feeling nervous and worrying about the
future, with racing thoughts




Medical History
This study source was downloaded by 100000822899794 from CourseHero.com on 04-20-2021 12:17:53 GMT -05:00

https://app.shadowhealth.com/assignment_attempts/8022602 2/6
https://www.coursehero.com/file/70056235/Mental-Health-Completed-Subjective-Shadow-Healthpdf/

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