Focused Exam Schizophrenia Completed Shadow Health PDF

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Summary

oBJECTIVE DATA FOR DCE MENTAL HEALTH...

Description

5/20/2021

Focused Exam: Schizophrenia | Completed | Shadow Health

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Focused Exam: Schizophrenia Results | Turned In NU309 - Mental Health Nursing - May 2021, (2021_summer_c16_term)__nu309km1 Return to Assignment (/assignments/493113/)

Your Results

Reopen (/assignment_attempts/9865544/reope Lab Pass (/assignment_attempts/9865544/lab_pass.

Overview

Subjective Data Collection: 37 of 37 (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 Care Plan

Category

Scored Items

Program Competency Progress

Patient Data Not Scored

Reflections

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

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

Chief Complaint

Established chief complaint

Reports hallucinations Has paranoid thoughts

History of Present Illness

Asked about onset and duration of symptoms

Reports hearing voices for the past 7 days Reports voices have increased over the last week Reports that voices are currently constant

Asked about characteristics of symptoms

Describes voices as sometimes male, sometimes female Denies visual hallucinations Denies gustatory hallucinations Denies olfactory hallucinations Denies tactile hallucinations

Followed up on content of hallucinations

Reports command hallucinations Reports resisting doing what the voices say

Asked about aggravating factors of symptoms

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5/20/2021

Focused Exam: Schizophrenia | Completed | Shadow Health Reports that voices are more disturbing in quie environments (when unable to be distracted)

Asked about coping strategies

Reports music as a coping strategy

Asked about existing health conditions

Denies general health conditions

Past Medical History

Asked about history of mental health

Reports diagnosis of schizophrenia Reports occasional insomnia Denies past history of depression Denies past history of anxiety Denies past history of bipolar disorder

Followed up on schizophrenia diagnosis

Followed up on insomnia

Diagnosed age 23

Reports frequent insomnia Reports difficulty falling asleep Reports recent insomnia has increased Reports sleeping 2 - 3 hours per night Reports frequent awakening Reports occasional nightmares

Asked about previous psychiatric hospitalizations

Followed up on previous hospitalizations

Reports previous psychiatric hospitalizations

Reports 3 previous hospitalizations All 3 hospitalizations were psychiatric admissions Reports first hospitalization was age 23 Reports second hospitalization was age 25 Reports third hospitalization was age 26

Asked about suicidal ideation and self-harm

Reports command hallucinations telling him to take a bottle of pills

Asked about past suicide attempts

Reports one past suicide attempt

Followed up on suicide planning

Denies intent to act on the command

Asked about homicidal ideation

Denies homicidal ideation

Home Medications

Asked about home medications and treatment of symptoms

Reports that he typically takes a prescribed medication for diagnosed schizophrenia Reports medication for insomnia Denies OTC medications Denies supplements or herbal formulas Denies vitamins

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Focused Exam: Schizophrenia | Completed | Shadow Health Asked about medication regimen adherence

Reports missing doses of medication for schizophrenia Reports being unsure of last dose of medicatio Reports that he was unable to continue taking because he tried to get it refilled, and insurance coverage wouldn't cover his usual prescription Reports that his mother was trying to help him get his usual prescription covered

Followed up on last dose of home medications

Followed up on medication for schizophrenia

Reports not remembering his last dose of medication

Medication name is Risperdal Denies remembering Risperdal dosage Takes medication twice a day Reports that medication typically is effective

Followed up on medication for insomnia

Medication name is trazodone Denies remembering trazodone dosage Takes medication as prescribed once daily at H Reports that medication is typically effective when taken.

Social History

Asked about drug use

Denies drug use

Asked about alcohol use

Reports some alcohol use

Followed up on alcohol use

Denies current alcohol in system Reports drinking 0 - 2 beers a week Denies binge drinking

Asked about tobacco and nicotine use

Followed up on tobacco and nicotine use

Reports smoking cigarettes

Reports smoking 1 PPD Reports smoking since age 16 Denies interest in quitting smoking

Asked about occupation and education

Reports currently working in a grocery store Reports working 20 - 30 hours / week Reports some college Currently in college working toward Audio Engineer degree

Asked about living situation, safety, and support system

Lives with mother Has no children Never married, in a relationship Reports not feeling safe at home

Asked about activities of daily living

Reports not bathing in the last week Reports not changing clothes in the last week Reports not being able to work in the last week

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Focused Exam: Schizophrenia | Completed | Shadow Health Reports not being able to go to school in the la week

Asked about appetite

Reports loss of appetite Reports unable to finish a meal Reports skipping meals Reports loss of appetite has gone on for the past week Reports not knowing when or what his last mea was

Review of Systems

Asked about general symptoms

Denies fever Denies chills Denies night sweats Denies fatigue Reports weight loss

Asked about review of systems for respiratory

Denies cough Denies shortness of breath Denies dyspnea on exertion Denies wheezing

Asked about review of systems for gastrointestinal

Denies abdominal pain Denies difficulty swallowing Denies nausea Denies vomiting Denies constipation Denies diarrhea Denies changes in stool or bowel patterns

Asked about review of systems for neurological

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

Asked about dental status

Denies dentures Denies loss of teeth Denies problems with teeth Reports last dentist visit was several years ago

Asked about awareness of involuntary movements

Asked if involuntary movements interfere with daily life

Denies abnormal involuntary movements

Denies abnormal involuntary movements interfering with life

Comments

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5/20/2021

Focused Exam: Schizophrenia | Completed | Shadow Health

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