Focused Exam Anxiety Completed Shadow Health PDF

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Summary

oBJECTIVE DATA FOR DCE MENTAL HEALTH...

Description

5/22/2021

Focused Exam: Anxiety | Completed | Shadow Health

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Focused Exam: Anxiety Results | Turned In NU309 - Mental Health Nursing - May 2021, (2021_summer_c16_term)__nu309km1 Return to Assignment (/assignments/493114/)

Your Results

Reopen (/assignment_attempts/9878904/reope Lab Pass (/assignment_attempts/9878904/lab_pass.

Overview

Subjective Data Collection: 36 of 36 (100.0%)

Transcript Subjective Data Collection Hover To Reveal...

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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Objective Data Collection Education & Empathy QSEN Competencies Documentation SBAR

Category

Scored Items

Reflections

Patient Data Not Scored

Student Survey

Experts selected these topics as essential components of a strong, thorough interview with this patient.

A combination of open and closed questions will yi better patient data. The following details are facts o patient's case.

Chief Complaint

Established chief complaint

Reports that he felt like he was "smothering" sense of chest pressure Reports feeling rapid heartbeat Reports sweating and shivering Reports shortness of breath

History of Present Illness

Asked about onset and duration of symptoms

Reports feeling started last night Reports feeling began at 3 am Reports that feeling has been constant since onset

Asked about aggravating factors of symptoms

Asked about relieving factors of symptoms

Reports that movement or anything besides resting seems to make the symptoms worse

Reports trying to take deep breaths Reports resting to try to feel calmer

Anxiety Screening https://herzing.shadowhealth.com/assignment_attempts/9878904

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5/22/2021

Focused Exam: Anxiety | Completed | Shadow Health Asked about anxiety

Reports excessive worry Reports worry frequency as occurring more days that not Reports excessive worry has happened for at least the last 6 months Reports unreasonable worry about work Reports unreasonable worry about health Reports occasionally feeling unable to control worry

Asked about restlessness

Reports occasional restlessness Reports occasionally feeling "keyed up" or "on edge" Denies feeling easily tired Denies problems concentrating Reports occasional irritability Denies muscle tension Denies anxiety interferes with daily life

Asked about changes in sleeping habits

Reports trouble getting to sleep (due to worry) Reports unsatisfying sleep Followed up on changes in sleep habits Denies taking sleep aids Reports 5 - 6 hours of sleep per night Reports taking 2 - 3 hours to fall asleep

Asked about changes in eating habits

Asked about depression

Denies changes in eating habits

Denies depression Denies losing interest in life Denies feelings of worthlessness or guilt

Asked about impact of alcohol or drugs on anxiety

Denies alcohol use caused failure to fulfill responsibilities Denies drug use caused failure to fulfill responsibilities Denies alcohol use placed him in a dangerous situation Denies drug use placed him in a dangerous situation Denies alcohol use resulted in arrest Denies drug use results in arrest Denies alcohol use caused problems with loved ones Denies drug use caused problems with loved ones

Past Medical History

Asked about existing health conditions

Reports hypertension Reports high cholesterol Reports osteoarthritis

Followed up on history of mental health

Denies past depression diagnosis Denies past anxiety diagnosis Denies past psychiatric admissions

https://herzing.shadowhealth.com/assignment_attempts/9878904

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Focused Exam: Anxiety | Completed | Shadow Health Followed up on hypertension diagnosis

Diagnosed at age 47 Reports occasionally checking BP at the pharmacy Reports belief that BP is well-controlled Reports typical numbers are 110/70

Followed up on high cholesterol diagnosis

Diagnosed at age 45

Followed up on osteoarthritis diagnosis

Diagnosed at age 46

Asked about allergies

Denies general allergies Denies environmental allergies Denies latex allergy

Asked specifically about medication allergies

Reports codeine allergy

Followed up on codeine allergy

Reports reaction is nausea and vomiting

Home Medications

Asked about home medications

Reports medication for hypertension Denies medication for osteoarthritis Reports medication for high cholesterol Reports taking fish oil capsules Denies taking vitamins Denies taking herbal supplements

Followed up on last dose of home medications

Reports no home meds taken today

Followed up on medication for cholesterol

Reports taking atorvastatin Reports atorvastatin dosage: 20 mg Reports atorvastatin frequency: 1x daily Denies atorvastatin side effects

Followed up on medication for hypertension

Reports taking lisinopril Reports lisinopril dosage: 10 mg Reports lisinopril frequency: 1x daily Denies lisinopril side effects

Family History

Asked about relevant family history

Reports mother had high cholesterol Reports father died of lung cancer, had hypertension Reports father died at age 50

Social History

Asked about substance use

Reports occasional alcohol use Denies recent alcohol use Denies illicit drug use Denies taking any form of stimulant

https://herzing.shadowhealth.com/assignment_attempts/9878904

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Focused Exam: Anxiety | Completed | Shadow Health Denies use of tobacco and nicotine products

Followed up on alcohol use

Drinks on the weekends Drinks 2 beers per day on the weekend

Asked about caffeine use

Drinks coffee Reports 2 cups of coffee every morning Denies that anxiety is impacted by caffeine

Asked about family, support system, and living situation

Reports being single Reports living alone Reports spending time with friends on the weekends Denies any spiritual activities Reports no support system

Review of Systems

Asked about general symptoms

Denies fever Denies chills Denies night sweats Denies weight loss

Asked about review of systems for HEENT

Reports blurry vision when he gets too worried Denies impaired hearing

Asked about review of systems for respiratory

Denies cough Denies dyspnea on exertion Denies wheezing

Asked about review of systems for cardiovascular

Reports palpitations Denies chest pain Denies edema Denies claudication

Asked about review of systems for skin, hair, and nails

Denies changes in hair Denies changes in skin Denies pruritus or easy bruising Denies pigmentation changes Denies rashes

Asked about review of systems for gastrointestinal

Denies nausea Denies abdominal pain Denies difficulty swallowing Denies vomiting Reports constipation Denies diarrhea

Asked about review of systems for musculoskeletal

Denies recent injury Denies joint pain Denies erythema Denies edema of joints

https://herzing.shadowhealth.com/assignment_attempts/9878904

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5/22/2021

Focused Exam: Anxiety | Completed | Shadow Health Asked about review of systems for neurological

Reports weakness Denies frequent headaches Denies syncope, dizziness, fainting, or vertigo Denies changes in coordination Denies changes in memory Denies recent falls

Asked about review of systems for psychological

Reports recent mood changes Denies hallucinations Denies suicidal ideation or self-harm

Comments If your instructor provides individual feedback on this assignment, it will appear here.

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