Mental Health Completed Shadow Health PDF

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Mental Health | Completed | Shadow Health If you are using Safari and have issues with audio in your assignment, please click here for assistance. Click here for more (/site_notice_dismissals?from_flash=true&site_not information (https://support.shadowhealth.com/hc/en-us/articles/360009548313)

Mental Health Results | Turned In nmen

Your Results

Overview

Subjective Data Collection: 37 of 44 (84.1%)

Transcript Subjective Data Collection Hover To Reveal...

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Objective Data Collection Education & Empathy Documentation

Category

Scored Items

Patient Data Not Scored

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

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

Chief Complaint

Established chief complaint

Reports difficulty sleeping and "feeling nervous" Reports seeking treatment because she has an upcoming exam and feels "too foggy to study" Reports excessive worry and "racing thoughts" before bed

History of Present Illness

Asked about onset and duration of symptoms

Reports difficulty sleeping began 3 1/2 weeks ag 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 sh can not redirect her thoughts from the things she is worried about Denies naps during the day

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1/6

Mental Health | Completed | Shadow Health 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 daily living

Reports feeling tired and "out of it" most of the 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 "out of it"

Asked about anxiety symptoms

Reports feeling slowed down and tired, having trouble focusing, and generally feeling "less sharp"

Reports feelings of anxiety as "thoughts she can't turn off" and "being on edge" Reports worry about the future, but no sense of impending doom Reports no panic attacks Reports difficulty concentrating due to fatigue from lack of sleep Reports only restlessness occurs just before bed Reports slight irritability due to fatigue

Asked about impact of anxiety on daily living

Reports stress only interferes with daily life because it interrupts her sleep Reports stress does not prevent her from completing her usual activities

Asked about sleep quality

Reports falling asleep often takes more than an hour Reports waking up two or three times during the night for "at least ten minutes" Reports waking in the morning feeling "out of it" and not rested

Asked about sleep habits

Reports going to bed "around midnight," but 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 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

2/6

Mental Health | Completed | Shadow Health Confirmed use of medications

Followed up about sleep medication use

Confirms medications (no new medications reported)

Denies taking OTC sleep medications Denies taking prescription sleep medications

Confirmed allergies

Asked about history of sleep problems

Confirms allergies (no new allergies reported)

Reports usually falls asleep very easily and "sleeps like a log" Reports only past sleep problems occurred for a few months after her father died, but they resolved on their own

Psychological History

Asked about history of psychiatric illness

Denies history of depression Denies history of anxiety Denies current psychiatric illness Denies history of psychiatric illness Denies bipolar disorder Denies schizophrenia Denies obsessive compulsive disorder Denies past psychiatric treatment Denies past psychotropic medications

Asked about symptoms to determine depression risk

Reports belief she does not have depression symptoms Reports no difficulty making decisions Reports slightly decreased energy due to lack of sleep Denies feelings of guilt or worthlessness Denies feelings of hopelessness Denies loss of enjoyment in activities usually found enjoyable Reports slightly less appetite because she feels "a little queasy" from lack of sleep Denies feelings of sadness

Asked about suicidal tendencies

Denies suicidal thoughts Denies suicidal behaviors Denies past suicide attempts

Asked about self-harm

Denies history of self-harm

Asked about past trauma

Denies past trauma

Asked about history of violent thoughts

Denies angry outbursts Denies past violent behavior Denies desire to harm others

Social History - Education and Work

Asked about employment status

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Currently employed

3/6

Mental Health | Completed | Shadow Health Works for a shipping company Works 32 hours a week Reports rarely missing work

Asked about education and learning ability

About to receive B.A. in Accounting Denies past special education courses Denies learning disabilities Denies speech problems Denies hearing problems

Asked about hobbies

Hobbies are reading and watching television

Asked about legal history

Denies past legal issues

Asked about military service

Denies military service

Social History - Housing and Support Network

Asked about living situation

Lives in a house Lives at home with mother and sister

Asked about family dynamics

Has a brother and a sister Father died in a car accident almost two years ago Reports family is "tight knit" and gets along well

Asked about support network

Reports close group of friends from middle and high school as well as from church Spends time with friends "a few times a month," though less so with her recent schedule

Asked about spirituality

Identifies as Baptist Reports attending Baptist church regularly since childhood

Social History - Substance Use

Asked about substance use

Reports past marijuana use Denies current substance use

Followed up on past marijuana use

Reports smoking marijuana for "five or six years" Reports last smoked marijuana when she was "20 or 21" years old Reports quitting marijuana because it "just wasn't fun anymore" and was bad for her asthma Reports marijuana use was for recreation, not to treat or mitigate specific symptoms

Asked about alcohol use

Confirms alcohol use Reports going out "a couple times a month" Reports having "a few drinks" when she goes out Reports 10-12 alcoholic drinks per month Reports drinking to "relax and blow off steam" Denies that anyone has asked her to stop drinking

4/6

Mental Health | Completed | Shadow Health Denies guilt associated with drinking

Asked about drinking and driving

Asked about tobacco use

Reports that she and her friends "usually take a cab"

Denies history of tobacco use Denies current tobacco use

Asked about prescription drug abuse

Denies prescription drug abuse

Social History - Relationship and Sexual History

Asked about relationship status

Asked about relationship history

Currently single

Reports past relationships Last relationship ended three years ago Most recent relationship lasted three years Reports she has never been married

Asked about sexual history

Reports past sexual relationships Reports three previous sexual partners Reports last sexual encounter was with boyfriend three years ago

Asked about abuse history

Denies history of abuse Denies past physical abuse Denies past verbal abuse

Social Determinants of Health

Asked about stress causes

Reports feeling stressed about studying and the future Reports CPA professional qualifying exam in one month Reports upcoming graduation from college and need to secure employment

Asked about stress coping

Reports coping with stress by going to church Reports coping with stress by staying organized Reports coping with stress by talking to friends and family Reports usual stress coping strategies are less effective

Family History

Asked about relevant family history

Denies psychiatric illness in the family Reports uncle has a "problem with alcohol" Denies family history of drug addiction Denies family history of suicide

5/6

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