Abigail Harris – Depression
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports feeling excessively weak
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting.
Asking about the chief complaint will allow the patient to voice any concerns or symptoms the
patient may have.
Example Question:
Do you feel weak?
Finding:
Reports fatigue and sleepiness
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting.
Asking about the chief complaint will allow the patient to voice any concerns or symptoms the
patient may have.
Example Question:
Are you fatigued?
History of Present Illness
Finding:
Asked about onset and duration of symptoms
,Finding:
Reports symptoms have been happening for past month
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
How often have you felt fatigued?
Finding:
Reports symptoms have been increasing in the past week
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Did the discomfort start gradually?
Finding:
Reports unable to get out of bed every morning
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Can you get out of bed?
Finding:
Asked about frequency, duration, and timing of symptoms
Finding:
,Reports feeling fatigued every morning
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Are you tired in the morning?
Finding:
Reports feeling slightly more energetic in the afternoon
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Are you tired in the afternoon?
Finding:
Asked about aggravating factors of symptoms
Finding:
Reports feeling is worse in the morning
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
When do the symptoms feel worse?
Finding:
Reports no known triggers
(Available)
, Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
What makes your symptoms worse?
Finding:
Asked about treatment and relieving factors of symptoms
Finding:
Reports that lying down feels best when fatigued
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
What relieves your symptoms?
Depression Screening
Finding:
Asked about pleasure and interest in typical activities
Finding:
Reports loss of interest in typical activities
(Found)
Pro Tip: Screening a patient for the symptoms of depression can lead to recommendations for
treatment and referrals. Depression can present with symptoms that affect sleep or appetite.
These screenings can also uncover if a patient is at risk for self-harm.
Example Question:
Do you have little interest in doing things?
Finding:
Reports not taking pleasure in things that typically would
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports feeling excessively weak
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting.
Asking about the chief complaint will allow the patient to voice any concerns or symptoms the
patient may have.
Example Question:
Do you feel weak?
Finding:
Reports fatigue and sleepiness
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting.
Asking about the chief complaint will allow the patient to voice any concerns or symptoms the
patient may have.
Example Question:
Are you fatigued?
History of Present Illness
Finding:
Asked about onset and duration of symptoms
,Finding:
Reports symptoms have been happening for past month
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
How often have you felt fatigued?
Finding:
Reports symptoms have been increasing in the past week
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Did the discomfort start gradually?
Finding:
Reports unable to get out of bed every morning
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Can you get out of bed?
Finding:
Asked about frequency, duration, and timing of symptoms
Finding:
,Reports feeling fatigued every morning
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Are you tired in the morning?
Finding:
Reports feeling slightly more energetic in the afternoon
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Are you tired in the afternoon?
Finding:
Asked about aggravating factors of symptoms
Finding:
Reports feeling is worse in the morning
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
When do the symptoms feel worse?
Finding:
Reports no known triggers
(Available)
, Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
What makes your symptoms worse?
Finding:
Asked about treatment and relieving factors of symptoms
Finding:
Reports that lying down feels best when fatigued
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
What relieves your symptoms?
Depression Screening
Finding:
Asked about pleasure and interest in typical activities
Finding:
Reports loss of interest in typical activities
(Found)
Pro Tip: Screening a patient for the symptoms of depression can lead to recommendations for
treatment and referrals. Depression can present with symptoms that affect sleep or appetite.
These screenings can also uncover if a patient is at risk for self-harm.
Example Question:
Do you have little interest in doing things?
Finding:
Reports not taking pleasure in things that typically would
