TINA JONES MENTAL HEALTH EXAM

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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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  • Available:

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

Patient Data

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

Chief Complaint

Finding:

Established chief complaint

Finding:

Reports difficulty sleeping and “feeling nervous”

(Available)

Pro Tip: Foundational questions to open an interview will help the patient tell you what’s bothering her in her own words.

Example Question:

What brings you in today?

Finding:

Reports seeking treatment because she has an upcoming exam and feels “too foggy to study”

(Available)

Pro Tip: Foundational questions will help the patient tell you what’s bothering her in her own words. It is important to ask Tina why she sought treatment to get an understanding of any recent changes with her complaint that could have made it more severe or urgent, prompting her to come in.

Example Question:

Why did you decide to seek treatment?

Finding:

Reports excessive worry and “racing thoughts” before bed

(Available)

Pro Tip: Foundational questions to open an interview will help the patient tell you what’s bothering her in her own words. Tina says that she “feels nervous” before bed, and it is interfering with her sleep. It is important to ask a follow-up question to gain more details about what feeling nervous means to her.

Example Question:

How do you feel just before bed?

History of Present Illness

Finding:

Asked about onset and duration of symptoms

Finding:

Reports difficulty sleeping began 3 1/2 weeks ago

(Available)

Pro Tip: Determining if the onset of a complaint was gradual or acute is important for diagnosis. In Tina’s case, you will need this information to assess what could be causing her sleep disturbance.

Example Question:

How long have you been having trouble sleeping?

Finding:

Reports sleep difficulties have been occurring regularly during past 3 1/2 weeks

(Available)

Pro Tip: Knowledge of the duration of a complaint will help you assess if the issue is recent or chronic. In Tina’s case, you will need this information to assess if she is suffering from chronic insomnia or a more acute sleep disturbance.

Example Question:

How long have your sleeping difficulties lasted?

Finding:

Asked about frequency of symptoms

Finding:

Reports difficulty sleeping at least four or five times a week

(Available)

Pro Tip: A precise question the number of occurrences of the issue in an allotted span of time will give you the most accurate estimation of frequency. In Tina’s case, it is important to know that she is suffering sleep disturbances for the majority of nights in a given week.

Example Question:

How many nights a week do you have trouble sleeping?

Finding:

Asked about aggravating factors

Finding:

Reports sleeping becomes more difficult when she can not redirect her thoughts from the things she is worried about

(Available)

Pro Tip: An open question about aggravating factors can be used to assess what could be exacerbating the patient’s complaint, as well as her knowledge of those factors. For Tina, it is important to understand what she thinks makes it more difficult for her to fall asleep.

Example Question:

What makes it harder to sleep?

Finding:

Denies naps during the day

(Available)

Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Though one short nap a day is fine, frequent or extended naps could have been making it more difficult for Tina to fall asleep, and could also indicate an inability to stay awake during her activities of daily living.

Example Question:

Do you take naps?

Finding:

Reports drinking caffeine to stay alert

(Available)

Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Though caffeine helps Tina to stay alert, drinking too much caffeine could interfere with her sleep.

Example Question:

Do you drink caffeine?

Finding:

Reports stopping caffeine use after 4 P.M.

(Available)

Pro Tip: This follow-up question is needed to assess how likely it is that caffeine consumption is interfering with sleep. If Tina were drinking caffeine late in the afternoon or at night, it would very likely be aggravating, or even causing, her sleep disturbance.

Example Question:

When do you usually have your last caffeinated drink?

Finding:

Denies alcohol use before bed

(Available)

Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Alcohol consumption before bed has been shown to interfere with homeostasis, which regulates sleep, and can even lead to insomnia, so it is important to know if Tina is drinking it to fall asleep.

Example Question:

Do you drink alcohol before bed?

Finding:

Denies drug use before bed

(Available)

Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. It is important to know if Tina is using drugs to help her fall asleep because they could, in fact, be contributing to her sleep disturbance.

Example Question:

Do you use drugs before bed?

Finding:

Reports respiratory problems are controlled and not interfering with sleep

(Available)

Pro Tip: A closed question about factors that are known to aggravate the complaint will help you to eliminate the most salient possibilities. Tina has asthma, and it is important to rule out respiratory issues as a contributing factor to, or even because of, her sleep disturbance. Tina also has an albuterol prescription, which, if she were using it before bed, could be aggravating or causing her anxiety.

Example Question:

Do you think your sleep problems could be due to breathing issues?

Finding:

Asked about relieving factors

Finding:

Reports sleeping more easily if she can distract herself from her “racing thoughts”

(Available)

Pro Tip: An open question about alleviating factors can be used to assess what brings relief to the patient, as well as her knowledge of those factors. For Tina, it is important to understand what she thinks makes it easier for her to fall asleep.

Example Question:

What helps you sleep?

Finding:

Reports no exercise

(Available)

Pro Tip: A closed question about factors known to alleviate the complaint will help you diagnose and treat the issue. Exercise is known to improve sleep, so it is important to assess Tina’s exercise level.

Example Question:

Do you exercise?

Finding:

Asked about impact of sleeping problems on daily living

Finding:

Reports feeling tired and “out of it” most of the time during the day due to lack of sleep

(Available)

Pro Tip: An open question about the effects of the complaint on a patient’s daily life will help you to get a general idea of the severity of the issue as well as allow you to understand how the patient is dealing with and affected by it. In Tina’s case, though her focus and energy is hampered by her sleep disturbance, she is able to perform all of her usual activities of daily living, meaning her insomnia is not severe, but it is debilitating.

Example Question:

How does your lack of sleep affect your daily life?

Finding:

Reports no increased chance of drifting off during the day despite lack of sleep

(Available)

Pro Tip: A closed question about a specific effect on daily life commonly seen with a patient’s complaint can help you to assess severity, diagnose, and treat it. If Tina were falling asleep without intending to, it could indicate a more severe sleep disorder as well as a more debilitating effect on her daily life.

Example Question:

Have you been falling asleep when you didn’t mean to?

Finding:

Followed up about patient’s experience feeling “out of it”

Finding:

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

(Available)

Pro Tip: When a patient uses phrasing that is unclear or not specific enough, it is important to ask a follow-up to ensure your understanding of the issue. Asking Tina what she means by “out of it” will help you to gain a more detailed idea of her state of mind during the day, and how it is affected by her sleep disturbance.

Example Question:

What do you mean when you say you feel out of it?

Finding:

Asked about anxiety symptoms

Finding:

Reports feelings of anxiety as “thoughts she can’t turn off” and “being on edge”

(Available)

Pro Tip: If a patient may have anxiety, asking about symptoms will aid diagnosis and determine severity. An open question about how Tina’s anxiety feels will help you to get a general idea of its character.

Example Question:

Can you tell me about how your anxiety feels?

Finding:

Reports worry about the future, but no sense of impending doom

(Available)

Pro Tip: If a patient may have anxiety, a sense of impending doom could indicate a panic disorder. Asking Tina about this will help you to come to a diagnosis and to determine severity.

Example Question:

Do you ever have a sense of impending doom?

Finding:

Reports no panic attacks

(Available)

Pro Tip: If a patient may have anxiety, it is important to determine if she is having panic attacks. Asking Tina about this will help you to come to a diagnosis and to determine severity, especially if she is experiencing panic before bed.

Example Question:

Have you been having panic attacks?

Finding:

Reports difficulty concentrating due to fatigue from lack of sleep

(Available)

Pro Tip: Difficulty concentrating is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity.

Example Question:

Have you been having trouble concentrating?

Finding:

Reports only restlessness occurs just before bed

(Available)

Pro Tip: Restlessness is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity.

Example Question:

Do you feel restless?

Finding:

Reports slight irritability due to fatigue

(Available)

Pro Tip: Irritability is an important indicator of generalized or situational anxiety. Asking Tina about this will help you to come to a diagnosis and to determine severity.

Example Question:

Do you feel irritable?

Finding:

Asked about impact of anxiety on daily living

Finding:

Reports stress only interferes with daily life because it interrupts her sleep

(Available)

Pro Tip: The effects of any complaint on a patient’s daily life are important. Asking Tina about the effects of her anxiety on her daily life will help you to come to a diagnosis and to determine severity.

Example Question:

How does your anxiety interfere with your daily life?

Finding:

Reports stress does not prevent her from completing her usual activities

(Available)

Pro Tip: The effects of any complaint on a patient’s daily life are important. Asking Tina about the effects of her anxiety on her daily life will help you to come to a diagnosis and to determine severity.

Example Question:

Does your anxiety prevent you from completing your usual activities?

Finding:

Asked about sleep quality

Finding:

Reports falling asleep often takes more than an hour

(Available)

Pro Tip: Sleep disorders may manifest in different ways, including difficulty falling asleep. In Tina’s case, it is important to know that falling asleep takes more than an hour, while normal sleep latency is only 15-20 minutes.

Example Question:

How long does it take you to fall asleep?

Finding:

Reports waking up two or three times during the night for “at least ten minutes”

(Available)

Pro Tip: Sleep disorders may manifest in different ways, including frequent awakenings. In Tina’s case, it is important to know how often she is waking often during the night, as well as how long it takes her to fall back asleep.

Example Question:

How often do you wake during the night?

Finding:

Reports waking in the morning feeling “out of it” and not rested

(Available)

Pro Tip: In assessing the severity of a sleep disorder, it is important to determine how rested a patient feels when she wakes up in the morning. Tina is waking up feeling tired and “out of it,” meaning her sleep disturbance is having a noticeable effect on her quality of sleep.

Example Question:

How do you feel when you wake up in the morning?

Finding:

Asked about sleep habits

Finding:

Reports going to bed “around midnight,” but feeling “too nervous” to sleep

(Available)

Pro Tip: A specific question about a patient’s bed time will elicit the information you need about when they try to fall asleep. In Tina’s case, it is important to know that she is getting into bed long before she falls asleep.

Example Question:

When do you go to bed?

Finding:

Reports actually falling asleep at 2 or 3 AM

(Available)

Pro Tip: A specific question about when a patient falls asleep will determine sleep latency as well as how much sleep the patient is actually getting. In Tina’s case, it is important to know that she often falls asleep long after she gets into bed.

Example Question:

When do you fall asleep?

Finding:

Reports reading before bed

(Available)

Pro Tip: A specific question about what a patient does before bed will help you to assess whether something she is doing could be contributing to the sleep disturbance. In Tina’s case, it is important to know that she reads before bed rather than immediately trying to fall asleep.

Example Question:

What do you usually do before bed?

Finding:

Reports no screen use (television or computer) before bed

(Available)

Pro Tip: The use of electronics before bed has been shown to stimulate brain activity, which can disturb sleep, and the artificial light from most screens may also affect melatonin levels, which regulate sleep cycles. It is important to know that Tina does not watch television or use a computer before bed to eliminate screen use as a possible contributing factor to her sleep disorder.

Example Question:

Do you watch television or use the computer before bed?

Finding:

Reports average wake time of 8 AM

(Available)

Pro Tip: A specific question about when a patient wakes up can determine if their sleep disturbance is causing early awakening. It is important to know that Tina is waking up at 8 AM, and that it is due to her schedule, not a result of sleep disturbance.

Example Question:

When do you usually wake up?

Finding:

Reports sleeping an average of 4 or 5 hours a night

(Available)

Pro Tip: Asking for the average number of hours of sleep a patient gets in one night will elicit the specific information you need to assess the severity of her sleep disorder. In Tina’s case, she is getting less sleep per night than is considered healthy.

Example Question:

How many hours of sleep do you get a night?

Finding:

Reports sleeping alone in a quiet room

(Available)

Pro Tip: A patient’s sleep environment can interfere with sleep. It is important to know that Tina has a quiet bedroom to herself to rule out anything from her environment that could be interrupting her sleep with or without her knowledge.

Example Question:

Can you describe where you sleep?

Finding:

Asked about stress quality

Finding:

Reports feeling nervous and worrying about the future, with racing thoughts

(Available)

Pro Tip: Stress can mean different things to different patients, so understanding how a patient experiences stress is essential. In Tina’s case, gathering details about her stress can help you to understand if it is situational or chronic, and how it could be aggravating or causing her sleep disturbance.

Example Question:

How do you feel when you are stressed?

Medical History

Finding:

Confirmed use of medications

Finding:

Confirms medications (no new medications reported)

(Available)

Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit. In Tina’s case, a new medication she is taking could be causing or aggravating her sleep disturbance.

Example Question:

Are you taking any new medications?

Finding:

Followed up about sleep medication use

Finding:

Denies taking OTC sleep medications

(Available)

Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit, especially if they are taking anything to treat their chief complaint. In Tina’s case, asking about over the counter sleep medications is important in understanding possible alleviating factors as well as if an over the counter sleep medication could be contributing to her drowsiness during the day.

Example Question:

Have you been taking over the counter medications to help you sleep?

Finding:

Denies taking prescription sleep medications

(Available)

Pro Tip: Even if you have seen a patient before, it is important to ask about medications in case they have changed since the last visit, especially if they are taking anything to treat their chief complaint. If Tina were taking prescription sleep medication, it could indicate that she has seen someone else about her sleep disturbance or that she has been treated for this problem in the past.

Example Question:

Have you been taking prescribed medication to help you sleep?

Finding:

Confirmed allergies

Finding:

Confirms allergies (no new allergies reported)

(Available)

Pro Tip: It’s best practice to ask a patient about her allergies each visit, even with an established patient, to uncover any new allergy triggers or symptoms.

Example Question:

Have you had any new allergies?

Finding:

Asked about history of sleep problems

Finding:

Reports usually falls asleep very easily and “sleeps like a log”

(Available)

Pro Tip: Assessing the history of a patient’s present illness is essential to diagnosis and treatment of the complaint. Knowing that until recently Tina hadn’t had similar sleep issues will help you narrow down possible causes.

Example Question:

Do you have a history of sleep problems?

Finding:

Reports only past sleep problems occurred for a few months after her father died, but they resolved on their own

(Available)

Pro Tip: Assessing the history of a patient’s present illness is essential to diagnosis and treatment of the complaint. Knowing that Tina had similar sleep problems during a difficult time in her life, and that the problem resolved itself, is integral to diagnosis and treatment.

Example Question:

Have you had difficulty falling asleep before?

Psychological History

Finding:

Asked about history of psychiatric illness

Finding:

Denies history of depression

(Available)

Pro Tip: Differentiating between depression and anxiety can sometimes be difficult, and often a patient will have both. Depression is also often a contributing factor in sleep disturbance, and sleep disturbance can also often contribute to depression. If Tina had a history of depression, it could be contributing to her sleep issues.

Example Question:

Have you ever had depression?

Finding:

Denies history of anxiety

(Available)

Pro Tip: Anxiety is a common cause of sleep disturbance, and lack of sleep can also contribute to anxiety issues. If Tina had a history of anxiety, it could be causing or aggravating her current sleep disturbance.

Example Question:

Do you have a history of anxiety?

Finding:

Denies current psychiatric illness

(Available)

Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about specific psychiatric disorders to rule them out.

Example Question:

Do you have a psychiatric illness?

Finding:

Denies history of psychiatric illness

(Available)

Pro Tip: As with any patient interview, it is important to ask about any relevant medical history. Tina is here for her mental health, so asking about her history of psychiatric illness is essential.

Example Question:

Do you have a history of psychiatric illness?

Finding:

Denies bipolar disorder

(Available)

Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about bipolar disorder to rule it out.

Example Question:

Do you have bipolar disorder?

Finding:

Denies schizophrenia

(Available)

Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about schizophrenia to rule it out.

Example Question:

Do you have schizophrenia?

Finding:

Denies obsessive compulsive disorder

(Available)

Pro Tip: When performing a mental health assessment, it is essential to do a complete mental status exam. However, asking a patient about possible current psychiatric illness in order to understand her mental health status is also important. In Tina’s case, you should ask her generally about her mental health, and you should also ask about obsessive compulsive disorder to rule it out.

Example Question:

Do you have obsessive compulsive disorder?

Finding:

Denies past psychiatric treatment

(Available)

Pro Tip: Even if a patient has not been diagnosed with a psychiatric illness, she could have seen a counselor, therapist, psychologist, or psychiatrist in the past. Asking Tina about past treatment could give you important context for diagnosis.

Example Question:

Do you have a history of psychiatric illness?

Finding:

Denies past psychotropic medications

(Available)

Pro Tip: Knowledge of past medications is integral to the history of the present illness. Tina is here for a mental health assessment, so it is important to ask her about any past medications for psychiatric illness.

Example Question:

Have you ever taken psychotropic medication?

Finding:

Asked about symptoms to determine depression risk

Finding:

Reports belief she does not have depression symptoms

(Available)

Pro Tip: While a patient with depression does not always know she has it, it is important to ask. If Tina had depression, it could be contributing to her sleep disturbance, or her sleep disturbance could be causing or aggravating or depression.

Example Question:

Do you have symptoms of depression?

Finding:

Reports no difficulty making decisions

(Available)

Pro Tip: Difficulty making decisions is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Do you have difficulty making decisions?

Finding:

Reports slightly decreased energy due to lack of sleep

(Available)

Pro Tip: An uncharacteristic lack of energy is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Have you had less energy than usual?

Finding:

Denies feelings of guilt or worthlessness

(Available)

Pro Tip: Feelings of guilt or worthlessness are important indicators of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Have you been feeling guilty for no reason?

Finding:

Denies feelings of hopelessness

(Available)

Pro Tip: Feelings of hopelessness are important indicators of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Have you been feeling hopeless?

Finding:

Denies loss of enjoyment in activities usually found enjoyable

(Available)

Pro Tip: A loss of enjoyment in activities usually found enjoyable is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Have you had trouble enjoying your usual activities?

Finding:

Reports slightly less appetite because she feels “a little queasy” from lack of sleep

(Available)

Pro Tip: An unusual increase or decrease in appetite is an important indicator of depression. Asking Tina about this will help you come to a differential diagnosis and determine severity.

Example Question:

Have you had a change in appetite?

Finding:

Denies feelings of sadness

(Available)

Pro Tip: Feeling sad is an important indicator of depression. Asking Tina about this will help you to come to a differential diagnosis and determine severity.

Example Question:

Have you been feeling sad?

Finding:

Asked about suicidal tendencies

Finding:

Denies suicidal thoughts

(Available)

Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had been thinking about or planning to commit suicide.

Example Question:

Have you ever had suicidal thoughts?

Finding:

Denies suicidal behaviors

(Available)

Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had ever engaged in suicidal behavior.

Example Question:

Have you ever done something that could end your life?

Finding:

Denies past suicide attempts

(Available)

Pro Tip: When assessing mental health risk factors, it is important to rule out your patient as a suicide risk. Tina would be considered a suicide risk if she had attempted suicide recently or in the past.

Example Question:

Have you attempted suicide in the past?

Finding:

Asked about self-harm

Finding:

Denies history of self-harm

(Available)

Pro Tip: Self-harm is an indicator of psychiatric disorders as well as a potential risk for suicide. Knowing if Tina has engaged in self-harm is important to assessing her mental health and her safety.

Example Question:

Have you ever intentionally hurt yourself?

Finding:

Asked about past trauma

Finding:

Denies past trauma

(Available)

Pro Tip: Recurring traumatic memories could indicate post-traumatic stress disorder, a significant aspect of a patient’s mental health and well-being. If Tina had traumatic memories, it would be important to assess PTSD as a risk factor.

Example Question:

Have you ever had repeated, disturbing memories of a stressful experience from the past?

Finding:

Asked about history of violent thoughts

Finding:

Denies angry outbursts

(Available)

Pro Tip: Difficulty controlling anger is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about anger is important in assessing her mental health and safety.

Example Question:

Have you ever had angry outbursts?

Finding:

Denies past violent behavior

(Available)

Pro Tip: Violence is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about violence is important in assessing her mental health and safety.

Example Question:

Have you ever behaved violently?

Finding:

Denies desire to harm others

(Available)

Pro Tip: Homicidal ideation or a desire to harm others is an indicator of psychiatric illness as well as a potential risk to others. Asking Tina about any potential desire to harm other people is important in assessing her mental health and safety.

Example Question:

Have you ever wanted to hurt someone else?

Social History – Education and Work

Finding:

Asked about employment status

Finding:

Currently employed

(Available)

Pro Tip: It is important to know whether or not a patient is employed when assessing her mental status. In Tina’s case, a change in her employment status could be a result of her mental health, or could be affecting it. The fact that she is employed lets you know she is financially secure, but it could also mean work is a source of her stress.

Example Question:

Are you employed?

Finding:

Works for a shipping company

(Available)

Pro Tip: A patient’s employment can be an indicator of financial stability, education level, personal interests, and level of responsibility. In Tina’s case, a different workplace could signal instability in her life, which could be a source of her stress. The fact that she is still employed by the same company indicates stability in this area of her life.

Example Question:

Where do you work?

Finding:

Works 32 hours a week

(Available)

Pro Tip: A patient’s work schedule is an indicator of her financial situation, as well as how demanding her employment may be on her time. In Tina’s case, her work schedule could be contributing to her stress levels.

Example Question:

How many hours a week do you work?

Finding:

Reports rarely missing work

(Available)

Pro Tip: Mental health issues can cause a patient to miss work; anxiety and depression, for instance, can make a patient less able to perform her daily responsibilities. If Tina were missing work lately, it could be an important indicator of a change in her mental health status.

Example Question:

How often do you miss work?

Finding:

Asked about education and learning ability

Finding:

About to receive B.A. in Accounting

(Available)

Pro Tip: A patient’s educational history can be an important indicator of economic and mental status, as well as her personal history and interests and any past developmental issues she may have had. In Tina’s case, she is about to achieve an educational milestone, which is a partial source of her stress, so it is especially important to ask her about it.

Example Question:

What is your highest education level?

Finding:

Denies past special education courses

(Available)

Pro Tip: A patient’s past developmental issues can be important indicators of mental status. Asking Tina about past specialized education is an important part of understanding her development.

Example Question:

Did you ever take special education classes?

Finding:

Denies learning disabilities

(Available)

Pro Tip: A patient’s past learning issues can be important indicators of mental status. Asking Tina about learning differences is an important part of understanding her development.

Example Question:

Do you have any learning differences?

Finding:

Denies speech problems

(Available)

Pro Tip: A patient’s speech development can be an important indicator of mental status. Asking Tina about speech difficulties is an important part of understanding her development.

Example Question:

Do you have difficulties with speech?

Finding:

Denies hearing problems

(Available)

Pro Tip: A patient’s hearing ability can be an important indicator of her mental status. Asking Tina about her hearing is an important part of understanding her development.

Example Question:

Do you have hearing difficulties?

Finding:

Asked about hobbies

Finding:

Hobbies are reading and watching television

(Available)

Pro Tip: A patient’s hobbies can help you to get to know her personality and interests better. Any recent change in hobbies, or a loss of interest in them, could indicate a change in mental health. Asking Tina about hobbies is also important in assessing her stress levels and the demands of her current schedule.

Example Question:

What do you do for fun?

Finding:

Asked about legal history

Finding:

Denies past legal issues

(Available)

Pro Tip: Recent or past legal issues are considered a significant indicator of mental status. If Tina had had any recent legal issues, it could indicate an important change in her mental health.

Example Question:

Have you ever had a legal problem?

Finding:

Asked about military service

Finding:

Denies military service

(Available)

Pro Tip: The demands and experiences of military service can have a profound effect on a patient’s mental health. If Tina had a history of military service, it would be an important part of understanding her feelings of stress and anxiety, and would indicate a need to explore the possibility of PTSD and other trauma.

Example Question:

Have you served in the military?

Social History – Housing and Support Network

Finding:

Asked about living situation

Finding:

Lives in a house

(Available)

Pro Tip: A patient’s housing is an indicator of finances and comfort. If Tina had recently undergone a change in housing, it could be contributing to her stress.

Example Question:

Can you tell me about your housing?

Finding:

Lives at home with mother and sister

(Available)

Pro Tip: A patient who lives with friends or family has a definite support system, so it is important to ask her about her living situation. If Tina had recently stopped living with her mother and sister, or if living with family were causing problems, this could be contributing to her stress.

Example Question:

Do you live with anyone?

Finding:

Asked about family dynamics

Finding:

Has a brother and a sister

(Available)

Pro Tip: A patient’s siblings can form part or all of her support network, and her relationship with them can indicate mental health status and/or childhood experiences, so asking about them is important. Tina lives with her sister and sees her brother often, which means they could be a source of support or stress for her.

Example Question:

Do you have siblings?

Finding:

Father died in a car accident almost two years ago

(Available)

Pro Tip: A patient’s parents can form part or all of her support network, and her relationship with them can indicate mental health status and/or child experiences, so asking about them is important. Tina lost her father almost two years ago, so assessing her feelings about that loss is important to assessing her mental health. Tina also lives with her mother, so their relationship could be an important source of support or stress.

Example Question:

Can you tell me about your parents?

Finding:

Reports family is “tight knit” and gets along well

(Available)

Pro Tip: How a patient gets along with family is an important indicator of the existence of a support network, childhood experiences, and/or mental health. Tina sees her family as her responsibility, but also as a source of support, so it is important to ask her about them in order to assess if they could be contributing to her stress.

Example Question:

Does your family get along well?

Finding:

Asked about support network

Finding:

Reports close group of friends from middle and high school as well as from church

(Available)

Pro Tip: It is important to ask a patient about her support network, including her friends. Asking Tina about her relationships with her friends is also important in assessing her stress levels and the demands of her current schedule.

Example Question:

Who are your friends?

Finding:

Spends time with friends “a few times a month,” though less so with her recent schedule

(Available)

Pro Tip: It is important to ask a patient about her support network, including her friends. Asking Tina about her relationships with her friends is also important in assessing her stress levels and the demands of her current schedule.

Example Question:

How often do you spend time with friends?

Finding:

Asked about spirituality

Finding:

Identifies as Baptist

(Available)

Pro Tip: Spirituality can be a significant factor in a patient’s mental status and coping strategies. Tina is a lifelong Baptist and regularly attends church, so it is important to ask her about her spirituality in order to assess her mental health.

Example Question:

What are your religious beliefs?

Finding:

Reports attending Baptist church regularly since childhood

(Available)

Pro Tip: Spirituality can be a significant factor in a patient’s mental status and coping strategies. Tina is a lifelong Baptist and regularly attends church, so it is important to ask her about her spirituality in order to assess her mental health.

Example Question:

Do you attend church regularly?

Social History – Substance Use

Finding:

Asked about substance use

Finding:

Reports past marijuana use

(Available)

Pro Tip: Substance abuse can be an indicator of, or a contributing factor to, psychiatric illness. Assessing Tina’s history of drug use is important to understanding her risk factors.

Example Question:

Have you ever used drugs?

Finding:

Denies current substance use

(Available)

Pro Tip: Substance abuse can be an indicator of, or a contributing factor to, psychiatric illness. Assessing Tina’s current drug use is important to understanding her risk factors.

Example Question:

Do you currently use drugs?

Finding:

Followed up on past marijuana use

Finding:

Reports smoking marijuana for “five or six years”

(Available)

Pro Tip: How long a patient used drugs can help you to assess any possibilities of addiction or relapse, as well as any potential negative effects on her physical or mental health. Asking Tina how long she smoked marijuana could help you to understand how her past drug use fits into her psychiatric history.

Example Question:

How long did you smoke marijuana?

Finding:

Reports last smoked marijuana when she was “20 or 21” years old

(Available)

Pro Tip: Any past substance use can be considered a risk factor, but if a patient had recently stopped using drugs it could indicate a potential for relapse or that drug use could still be affecting her mental health. Asking Tina how long ago she stopped smoking marijuana could help you to understand how her past drug use fits into her psychiatric history.

Example Question:

When did you stop smoking marijuana?

Finding:

Reports quitting marijuana because it “just wasn’t fun anymore” and was bad for her asthma

(Available)

Pro Tip: A patient may have stopped using substances due to adverse effects on her mental and physical wellbeing. Asking Tina why she stopped smoking marijuana could help you to understand how her substance use affected her mentally and physically.

Example Question:

Why did you stop smoking marijuana?

Finding:

Reports marijuana use was for recreation, not to treat or mitigate specific symptoms

(Available)

Pro Tip: A patient may use substances as a form of self-medication for psychiatric illness. Asking Tina why she smoked marijuana could help you to understand how her past drug use fits into her psychiatric history.

Example Question:

Why did you smoke marijuana?

Finding:

Asked about alcohol use

Finding:

Confirms alcohol use

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina’s alcohol use could be a risk factor, so it is important to assess her alcohol consumption in order to rule out addiction or dependency.

Example Question:

Do you drink alcohol?

Finding:

Reports going out “a couple times a month”

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. Knowing how often she drinks alcohol will help you to asses if her use of it is a risk factor.

Example Question:

How often do you drink alcohol?

Finding:

Reports having “a few drinks” when she goes out

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. Knowing how much alcohol she drinks will help you to asses if her use of it is a risk factor.

Example Question:

How much alcohol do you drink?

Finding:

Reports 10-12 alcoholic drinks per month

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Tina drinks alcohol, so it is important to ask her follow-up questions in order to rule out dependency and addiction when assessing her mental health. It is essential, when checking for risk of alcohol dependency, to ask specific questions in order to discern exactly how many drinks she has per month.

Example Question:

How many drinks do you have per month?

Finding:

Reports drinking to “relax and blow off steam”

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. Asking Tina why she drinks alcohol can help you to rule out self-medication and/or dependency.

Example Question:

Why do you drink alcohol?

Finding:

Denies that anyone has asked her to stop drinking

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. If people close to Tina had asked her to stop drinking, it would be an important indicator of possible alcohol dependency.

Example Question:

Has anyone asked you to stop drinking?

Finding:

Denies guilt associated with drinking

(Available)

Pro Tip: Alcohol abuse can be an indicator of, or a contributing factor to, psychiatric illness. If Tina felt guilty after drinking, it could indicate she was drinking too much, and/or engaging in risky or uncharacteristic behavior when under the influence, which would be an important indicator of possible alcohol dependency.

Example Question:

Do you ever feel guilty after drinking?

Finding:

Asked about drinking and driving

Finding:

Reports that she and her friends “usually take a cab”

(Available)

Pro Tip: Driving under the influence is dangerous, and it can indicate alcohol dependency. If Tina were driving drunk, or riding in cars with a drunk driver, it would indicate alcohol dependency as a risk factor.

Example Question:

How do you get home when you have been drinking?

Finding:

Asked about tobacco use

Finding:

Denies history of tobacco use

(Available)

Pro Tip: Tobacco can affect mental health, so it is important to ask a patient about her tobacco use. Asking Tina about tobacco is recommended because it can contribute to stress and feelings of anxiety.

Example Question:

Have you ever used tobacco?

Finding:

Denies current tobacco use

(Available)

Pro Tip: Tobacco can affect mental health, so it is important to ask a patient about her tobacco use. Asking Tina about tobacco use is recommended because tobacco can contribute to stress and feelings of anxiety.

Example Question:

Do you use tobacco?

Finding:

Asked about prescription drug abuse

Finding:

Denies prescription drug abuse

(Available)

Pro Tip: Abuse of prescription drugs can be an indicator of, or a contributing factor to, psychiatric illness. If Tina were abusing prescription drugs it would be a definite risk factor for her mental health.

Example Question:

Have you taken drugs not prescribed to you?

Social History – Relationship and Sexual History

Finding:

Asked about relationship status

Finding:

Currently single

(Available)

Pro Tip: Romantic and sexual relationships are an important part of a patient’s support system, but they can also be a source or indicator of stress. If Tina were in a relationship, it would be important to follow-up for more details on the nature and quality of that relationship.

Example Question:

Are you in a relationship?

Finding:

Asked about relationship history

Finding:

Reports past relationships

(Available)

Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress.

Example Question:

Have you been in a relationship in the past?

Finding:

Last relationship ended three years ago

(Available)

Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress.

Example Question:

When was your last relationship?

Finding:

Most recent relationship lasted three years

(Available)

Pro Tip: Understanding a patient’s relationship history is integral to assessing her mental health. In Tina’s case, a change in her relationship status could be a source of her current stress.

Example Question:

How long was your last relationship?

Finding:

Reports she has never been married

(Available)

Pro Tip: Understanding a patient’s marital history is integral to assessing her mental health. If Tina had been married, it could be a current source of her stress.

Example Question:

Have you ever been married?

Finding:

Asked about sexual history

Finding:

Reports past sexual relationships

(Available)

Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status.

Example Question:

Have you had sex in the past?

Finding:

Reports three previous sexual partners

(Available)

Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status.

Example Question:

How many sexual partners have you had?

Finding:

Reports last sexual encounter was with boyfriend three years ago

(Available)

Pro Tip: Understanding a patient’s sexual history and experiences is integral to assessing her mental health. If Tina had anxiety about her sexual history, it could indicate past trauma, or if Tina had a recent change in her sexual pattern it could indicate a change in her mental status.

Example Question:

When did you last have sex?

Finding:

Asked about abuse history

Finding:

Denies history of abuse

(Available)

Pro Tip: A history of abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma.

Example Question:

Do you have a history of abuse?

Finding:

Denies past physical abuse

(Available)

Pro Tip: Physical abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma.

Example Question:

Have you ever been physically abused?

Finding:

Denies past verbal abuse

(Available)

Pro Tip: Verbal abuse can have an enormous effect on a patient’s mental health. If Tina had suffered abuse, it could mean her feelings of stress and anxiety were related to that past trauma.

Example Question:

Have you ever been verbally abused?

Social Determinants of Health

Finding:

Asked about stress causes

Finding:

Reports feeling stressed about studying and the future

(Available)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

What seems to be causing your stress?

Finding:

Reports CPA professional qualifying exam in one month

(Available)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

What test are you trying to study for?

Finding:

Reports upcoming graduation from college and need to secure employment

(Available)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

What about the future is causing you stress?

Finding:

Asked about stress coping

Finding:

Reports coping with stress by going to church

(Available)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

How do you cope with stress?

Finding:

Reports coping with stress by staying organized

(Available)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

How do you manage stress?

Finding:

Reports coping with stress by talking to friends and family

(Available)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

Who do you talk to about stress?

Finding:

Reports usual stress coping strategies are less effective

(Available)

Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.

Example Question:

Do your coping strategies help your stress?

Family History

Finding:

Asked about relevant family history

Finding:

Denies psychiatric illness in the family

(Available)

Pro Tip: Many psychiatric illnesses are hereditary, so knowing the patient’s family psychiatric history is essential to assessing her mental health. In Tina’s case, a family history of anxiety or depression could be significant in reaching a diagnosis.

Example Question:

Has anyone in your family had a psychiatric illness?

Finding:

Reports uncle has a “problem with alcohol”

(Available)

Pro Tip: Substance abuse and addiction often runs in families, so knowing the patient’s family history of substance abuse is essential to assessing her mental health. In Tina’s case, a significant family history of addiction could be considered a risk factor.

Example Question:

Do you have a family history of alcohol dependency?

Finding:

Denies family history of drug addiction

(Available)

Pro Tip: Substance abuse and addiction often runs in families, so knowing the patient’s family history of substance abuse is essential to assessing her mental health. In Tina’s case, a significant family history of addiction could be considered a risk factor.

Example Question:

Do you have a family history of drug addiction?

Finding:

Denies family history of suicide

Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation
Subjective

(No Documentation Made)

HPI: Ms. Jones presents to the clinic complaining of difficulty sleeping which she notes to have started 1 month ago. She states that her sleep is “shallow and not restful”. She complains of difficulty falling asleep at least 4 or 5 nights per week, but states that she is able to stay asleep without difficulty. On average she sleeps 4 or 5 hours per night and awakens at 8:00am daily. She states that she has a fairly consistent schedule on weekdays and weekends. She does not take any prescription or over the counter sleep aids. She limits screen time prior to bed and does not ingest caffeine after 4pm daily. She endorses decreased feelings of sleepiness over the past month. She denies difficulties awaking, but does not feel rested in the morning and has daytime fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity). She does not take naps. Social History: She states that she has some stress related to her upcoming examinations and her impending job search upon graduation. She states that she has a strong support system made up of friends and family and she is active in her church. She states that she copes with stress by staying organized. She enjoys reading and watching television (1-2 hours per day). She states that her father died in a car accident a year and a half ago, which was difficult for her and she experienced some difficulties with sleep at that time as well. She denies use of tobacco. She drinks approximately 10-12 alcoholic beverages per month, but never more than 3 per sitting and does not note any impact on her sleep. She has used marijuana in the past, but no current use and denies other illicit drugs. She does not exercise regularly, but states that her job is somewhat active and she walks 5-15 minutes daily. She drinks 1-3 diet colas per day. Family History: Denies any history of known sleep disorders or psychiatric disorders. Review of Systems: • General: Denies changes in weight, weakness, fever, chills, and night sweats. Does complain of increasing daytime fatigue. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. Endorses changes in concentration and sleep. Denies changes or difficulties in coordination. • Psychiatric: States that her mood has been “off” and she does not feel like herself. She does complain of increased anxiety related to upcoming exams and job search. She has no history of depression, but does state that she feels helpless and notes that her performance at work and school is beginning to decline. She denies tension or memory loss. No past suicide attempts. Denies suicidal or homicidal ideation.
Assessment

(No Documentation Made)

Sleep disturbance related to anxiety
Plan

(No Documentation Made)

• Encourage Ms. Jones to continue to monitor symptoms and log her episodes of insomnia and anxiety with associated factors and bring log to next visit. • Encourage to decrease caffeine consumption and increase intake of water and other fluids. • Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery. Continue to monitor and explore the need for possible referral to social work/psychiatry or pharmacologic intervention. • Discuss need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2pm, limiting fluids after dinner, limiting screen time or stimulating activities after 8pm, and to get out of bed if awaken in the middle of the night. • Educate to limit alcohol and depressant medications (including diphenhydramine and Tylenol PM). • Educate on when to seek further or emergent care including feelings of self-harm or hopelessness. • Revisit clinic in 2-4 weeks for follow up and evaluation.

 

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