Mental Health Results

Mental Health Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

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Transcript

Started: Apr 20, 2020 | Total Time: 77 min

Gree 04/20/20 6:52 PM MD

Question 04/20/20 6:52 PM MD

Empathize 04/20/20 6:53 PM MD

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Empathize 04/20/20 6:55 PM MD

Your Results Lab Pass (/assignment_attempts/6690008/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Interview Questions (116) Statements (34) Exam Actions (0)

Hello Miss Jones my name is Doris and it’s good to see you again

Hey.

How are you doing today

I’m not doing too great, honestly. I’ve been feeling nervous before bed and having a lot of trouble sleeping lately.

I’m sorry that must be difficult for you I’m happy that you’re here today to talk about it

I appreciate you saying that.

Is that what brings you here today

I decided to come in because I’m tired all the time now. . . I have this really important exam coming up, and I’m stressed and too foggy to study most of the time. I really need help sleeping so I can focus on preparing for my exam.

How long have you had trouble sleeping

This all started almost a month ago. . . it’s been happening regularly for about three and a half weeks, I’d say.

I’m sorry you must be feeling really tired

Thanks.

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Have you had this problem before

Well. . . the only other time I’ve had sleep problems was right after Dad died. It felt a little like this, with my mind racing, but honestly, not as bad. Other than that month or two, I’ve always been a really good sleeper. I could fall asleep right away, and then I’d sleep like a log.

Can you describe what your feeling before you go to bed

It’s like. . . once it gets close to bed time, I start feeling on edge, even though I’ve been pretty tired all day. Then once the light’s off and I try to sleep, my mind just starts racing, and I think about all the things in the future that I’m stressed out about.

I’m sorry to hear that

I appreciate you telling me that.

Is there anything that AGGRAVATES THESE SYMPTOMS

Basically, the more I think about what I’m worried about, the worse it is. Sometimes I can distract myself and not let myself start thinking about all the things that stress me out, but that’s been rare.

Is there something that makes it better

Basically the only way I get to sleep easily is if I manage to feel less stressed out–sometimes I can sort of turn my thoughts away from what I’m worried about by distracting myself with something, like thinking about what I’m going to wear the next day or something like that. I’d rather avoid having to take medication if possible. Taking deep breaths can help a little, too.

Is there any other symptoms that happens with difficult sleeping (Clarified to What about other symptoms?.)

When I feel anxious, it’s like. . . I’m kind of on edge and nervous, and my thoughts start racing, and I just think about all the things there are to worry about. (Clarified to what other symptoms I have.)

Have you had any medication for this before (No matching questions found.)

Have you ever had anxiety before

Lately I’ve felt pretty anxious, I guess. . . mostly right before bed. I just feel on edge, and like my thoughts can’t turn off when I want them to.

Do you take naps in the day

I’m not really a big nap person–if I fall asleep, I want to sleep for hours, not wake up in twenty minutes feeling groggy. Plus I don’t have time for them, anyway.

Do you drink a lot of caffeine

 

 

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Honestly, I know I have to limit my caffeine, especially since I’m having trouble sleeping, but I feel so foggy during the day that I really need something to wake me up, so I’ve been having a few diet Cokes over the course of the morning.

Can I ask how many coats do you get a day (No matching questions found.)

HOW MANY COKES DO YOU DRINK IN A DAY

I drink maybe four diet sodas a day.

What time is the last time you drink Coke

I know it’s bad to drink too much caffeine, especially when you’re having sleep problems, so I try not to drink it after the morning. I definitely never have any diet Cokes after 4 PM at the latest.

Do you drink any alcohol

I do sometimes, yeah, when I go out with my friends.

How often do you go out with your friends

I see my friends pretty often–I’ll go out with my girls once a week or so, and I see friends at church too.

Hanging out with friends can help you with your stress

Sure, I think I understand what you mean.

Your church friends must be very supportive

Thanks for telling me.

Do you take illicit drugs

No.

I’m sorry to hear about your father

Thanks for understanding.

Have you had any counseling after your father passed away (No matching questions found.)

Have you had any counseling for depression

I don’t think I’m depressed.

 

 

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Were you depressed when your father passed away (Clarified to Did you get depressed after your dad died?.)

I wouldn’t say I was depressed–I know that’s really serious. I was just sad and grieving. It was really hard, but over time, it got better. I miss him every day, but I know God is taking care of him. (Clarified to if I got depressed after my dad died.)

It is normal to be sad when A LOVED ONE PASSES, I am happy you were able to handle that

Alright, thanks for letting me know.

Do you have any trouble breathing when you’re trying to fall asleep (Clarified to Do you have trouble breathing at night?.)

My breathing has been fine since I started the daily inhaler, actually. (Clarified to if I have trouble breathing at night.)

Can you tell me your medical history

I’ve had asthma since I was little, and I have sugar diabetes, too.

Are you taking medication for your asthma

I just use my inhaler.

How often are you using your inhaler

Yeah. Two puffs, twice a day. I’ve been good about taking all my doses.

What is the name of your medication (Clarified to What medications do you take?.)

All I have is a Proventil inhaler and a Flovent inhaler for my asthma. (Clarified to what medications I am taking.)

When was your last asthma attack

Well, I use my daily inhaler every day. I haven’t had to use my rescue inhaler in maybe nine months.

Have you ever been hospitalized for asthma

I went a bunch of times when I was little, for asthma attacks.

Are you taking medication for diabetes

I don’t take anything for my diabetes anymore.

Your diabetes must be under control that’s good news

 

 

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OK, I understand.

Do you exercise

I just don’t have time to exercise, honestly.

How does difficulty sleeping have an impact on your daily activities (No matching questions found.)

does your difficult sleeping impact your daily activities

Well. . . I’m tired all day, and I feel kind of out of it. That makes it hard to focus and get things done, especially when I try to study for my exam coming up. It’s pretty frustrating.

Do you drift off to sleep in the middle of the day

No, though I do feel groggy during the day.

That must be very difficult for you I’m sorry to hear that

Thanks for saying that.

What do you mean by being out of it

It’s like. . . I just feel slowed down and tired all the time from not sleeping. It’s harder to focus, or get things done efficiently. . . I’m just generally less sharp.

I must be very difficult for you

I appreciate you saying that.

Do you have any anxiety or thoughts that you can’t turn off (No matching questions found.)

do you have thoughts that you can’t turn off (Clarified to Have you ever had thoughts of suicide?.)

No, never. (Clarified to if I have ever thought about suicide.)

When you’re worried do you feel impending doom (Clarified to Do you ever have a sense of impending doom?.)

No, I don’t feel doomed, just worried about stuff, especially not being able to sleep when there’s so much to do. (Clarified to if I ever have a sense of impending doom.)

Panic attacks (Clarified to Have you ever had a panic attack?.)

I’ve never had a panic attack, no. (Clarified to if I have ever had a panic attack.)

 

 

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Do you have trouble concentrating do to your fatigue (Clarified to How often are you having trouble concentrating?.)

Ever since these sleep problems started, I notice some trouble concentrating. I feel a little out of it sometimes. (Clarified to how often I have difficulty focusing.)

That must be really hard on you sorry to hear that

Thanks for understanding.

Do you feel irritable

I feel like little setbacks annoy me more since my sleep trouble started. . . like if I can’t find my keys, or I get stuck at a red light, it’s harder for me to be patient about it.

Tell me more about your stress

When I feel anxious, it’s like. . . I’m kind of on edge and nervous, and my thoughts start racing, and I just think about all the things there are to worry about.

What are you worried about

Mostly I start out worrying about this exam I have coming up, and how much I need to study, and then I start thinking about what happens if I don’t pass the exam, and even if I do, whether I’ll actually be able to find an accounting job once I graduate, and then if I do find a job, what if I’m bad at it. . . it just sort of builds on itself like that, just, like, worry upon worry.

Can totally understand where you’re coming from I am sorry that you are worried about the future

Thanks for saying that.

It might help to start up just taking one day at a time

That makes sense.

It might be good to have a goal task daily

OK, I understand.

Does stress prevent you from completing your activities

Being anxious is mostly just interfering with my sleep, and then not being able to get enough sleep is interfering with my life.

How is it interfering with your life (No matching questions found.)

When you fall asleep how long do you sleep (Clarified to What time do you fall asleep?.)

 

 

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I get into bed around midnight, but then I’ll read because I can feel myself start to stress about stuff and I need a distraction. So I’ll actually turn of the light and close my eyes around 1 or so, and then I won’t fall all the way asleep for another hour and a half, two hours, usually. Sometimes, if I really start stressing out, I’ll even turn the light back on and read more until I feel more wound down. (Clarified to when I usually go to sleep.)

How much sleep do you get a night

Not much. . . 4 or 5 hours a night, usually.

Can you describe your sleep habits

Well. . . I usually get into bed around midnight, but at that point I feel too nervous to sleep, so I’ll read to try and wind down for maybe an hour, sometimes longer. Then I turn out the light and try to sleep. If it takes a really long time, then sometimes I’ll turn the light back on and read a little more until I feel sleepier.

What time do you wake up in the morning

I have to be out of bed by 8 every morning.

Do you sleep alone

Yep. [AUDIO COMING SOON]

Do you do anything to cope with stress (Clarified to How do you cope with stress?.)

Usually I try to stay organized, you know, make to-do lists, plan my time, that kind of thing. Sometimes I’ll talk to friends or family. . . going to church usually helps, too. Lately, though, none of that is really helping like it should. (Clarified to how I cope with stress.)

I’m so sorry to hear that

Thanks.

Friends are very important in helping you cope with stress

Thanks for telling me.

Do you take medication for stress

No, luckily I’ve never needed that.

Are you allergic to any medication

Yeah, I’m allergic to penicillin.

What happens if penicillin (Clarified to What type of reaction do you have to penicillin?.)

 

 

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I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that. (Clarified to what my reaction to penicillin is.)

I’m glad to know that you know your allergy to penicillin

Alright, thanks for letting me know.

Do you take over the counter medication for stress (Clarified to Have you been taking over the counter sleep medications?.)

No, I haven’t tried taking anything to sleep. I’d rather avoid having to take medication if possible. (Clarified to if I have been taking over the counter sleep medication.)

Do you take any over-the-counter medication

I take Tylenol for a headache sometimes, or Advil for cramps, but not often.

Have you had any psychiatric illness

My mental health has always been fine, fortunately.

Do you have any bipolar disorder

No.

Do you have any schizophrenia

No, I don’t.

Do you have any obsessive compulsive disorder

No. I feel really lucky that I haven’t had to deal with that.

Have you ever had any psychiatric treatment (Clarified to Do you have a history of psychiatric treatment?.)

I’ve never needed to see a therapist or anything. (Clarified to if I have a history of psychiatric treatment.)

Have you had any mental illness

My mental health has always been fine, fortunately.

Are you able to make decisions

No. I know I probably should, but that kind of thing just feels really morbid to me.

 

 

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Do you ever feel guilty or worthlessness

I really try hard not to do anything I would feel guilty about, and it works–I don’t really ever feel guilty about anything. And if I do, I pray on it.

Mental health is an important part of our well-being

Sure, I think I understand what you mean.

Have you ever felt hopelessness

I don’t feel hopeless, just frustrated and stressed out.

Do you find your job enjoyable

I like my job, especially since being promoted to shift supervisor. I like the people I work with . . . and I can see myself moving up when I finish my degree.

That’s good to hear I’m proud of you

I appreciate you telling me that.