Subjective Data Collection: 0 of 44 (0.0%)<\/strong><\/p>\n Hover To Reveal…<\/p>\n Hover over the\u00a0Patient Data\u00a0<\/strong>items below to reveal important information, including\u00a0Pro Tips<\/strong>\u00a0and\u00a0Example Questions<\/strong>.<\/p>\n Indicates an item that you found.<\/p>\n Indicates an item that is available to be found.<\/p>\n Category<\/strong><\/p>\n Scored Items<\/strong><\/p>\n <\/p>\n Experts selected these topics as essential components of a strong, thorough interview with this patient.<\/p>\n Patient Data<\/strong><\/p>\n Not Scored<\/strong><\/p>\n A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.<\/p>\n Chief Complaint<\/strong><\/p>\n Finding:<\/p>\n Established chief complaint<\/p>\n Finding:<\/p>\n Reports difficulty sleeping and “feeling nervous”<\/p>\n (Available)<\/p>\n Pro Tip: Foundational questions to open an interview will help the patient tell you what’s bothering her in her own words.<\/p>\n Example Question:<\/p>\n What brings you in today?<\/p>\n Finding:<\/p>\n Reports seeking treatment because she has an upcoming exam and feels “too foggy to study”<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Why did you decide to seek treatment?<\/p>\n Finding:<\/p>\n Reports excessive worry and “racing thoughts” before bed<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How do you feel just before bed?<\/p>\n History of Present Illness<\/strong><\/p>\n Finding:<\/p>\n Asked about onset and duration of symptoms<\/p>\n Finding:<\/p>\n Reports difficulty sleeping began 3 1\/2 weeks ago<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How long have you been having trouble sleeping?<\/p>\n Finding:<\/p>\n Reports sleep difficulties have been occurring regularly during past 3 1\/2 weeks<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How long have your sleeping difficulties lasted?<\/p>\n Finding:<\/p>\n Asked about frequency of symptoms<\/p>\n Finding:<\/p>\n Reports difficulty sleeping at least four or five times a week<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How many nights a week do you have trouble sleeping?<\/p>\n Finding:<\/p>\n Asked about aggravating factors<\/p>\n Finding:<\/p>\n Reports sleeping becomes more difficult when she can not redirect her thoughts from the things she is worried about<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n What makes it harder to sleep?<\/p>\n Finding:<\/p>\n Denies naps during the day<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you take naps?<\/p>\n Finding:<\/p>\n Reports drinking caffeine to stay alert<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you drink caffeine?<\/p>\n Finding:<\/p>\n Reports stopping caffeine use after 4 P.M.<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n When do you usually have your last caffeinated drink?<\/p>\n Finding:<\/p>\n Denies alcohol use before bed<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you drink alcohol before bed?<\/p>\n Finding:<\/p>\n Denies drug use before bed<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you use drugs before bed?<\/p>\n Finding:<\/p>\n Reports respiratory problems are controlled and not interfering with sleep<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you think your sleep problems could be due to breathing issues?<\/p>\n Finding:<\/p>\n Asked about relieving factors<\/p>\n Finding:<\/p>\n Reports sleeping more easily if she can distract herself from her “racing thoughts”<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n What helps you sleep?<\/p>\n Finding:<\/p>\n Reports no exercise<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you exercise?<\/p>\n Finding:<\/p>\n Asked about impact of sleeping problems on daily living<\/p>\n Finding:<\/p>\n Reports feeling tired and “out of it” most of the time during the day due to lack of sleep<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How does your lack of sleep affect your daily life?<\/p>\n Finding:<\/p>\n Reports no increased chance of drifting off during the day despite lack of sleep<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you been falling asleep when you didn’t mean to?<\/p>\n Finding:<\/p>\n Followed up about patient’s experience feeling “out of it”<\/p>\n Finding:<\/p>\n Reports feeling slowed down and tired, having trouble focusing, and generally feeling “less sharp”<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n What do you mean when you say you feel out of it?<\/p>\n Finding:<\/p>\n Asked about anxiety symptoms<\/p>\n Finding:<\/p>\n Reports feelings of anxiety as “thoughts she can’t turn off” and “being on edge”<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Can you tell me about how your anxiety feels?<\/p>\n Finding:<\/p>\n Reports worry about the future, but no sense of impending doom<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you ever have a sense of impending doom?<\/p>\n Finding:<\/p>\n Reports no panic attacks<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you been having panic attacks?<\/p>\n Finding:<\/p>\n Reports difficulty concentrating due to fatigue from lack of sleep<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you been having trouble concentrating?<\/p>\n Finding:<\/p>\n Reports only restlessness occurs just before bed<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you feel restless?<\/p>\n Finding:<\/p>\n Reports slight irritability due to fatigue<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you feel irritable?<\/p>\n Finding:<\/p>\n Asked about impact of anxiety on daily living<\/p>\n Finding:<\/p>\n Reports stress only interferes with daily life because it interrupts her sleep<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How does your anxiety interfere with your daily life?<\/p>\n Finding:<\/p>\n Reports stress does not prevent her from completing her usual activities<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Does your anxiety prevent you from completing your usual activities?<\/p>\n Finding:<\/p>\n Asked about sleep quality<\/p>\n Finding:<\/p>\n Reports falling asleep often takes more than an hour<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How long does it take you to fall asleep?<\/p>\n Finding:<\/p>\n Reports waking up two or three times during the night for “at least ten minutes”<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How often do you wake during the night?<\/p>\n Finding:<\/p>\n Reports waking in the morning feeling “out of it” and not rested<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How do you feel when you wake up in the morning?<\/p>\n Finding:<\/p>\n Asked about sleep habits<\/p>\n Finding:<\/p>\n Reports going to bed “around midnight,” but feeling “too nervous” to sleep<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n When do you go to bed?<\/p>\n Finding:<\/p>\n Reports actually falling asleep at 2 or 3 AM<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n When do you fall asleep?<\/p>\n Finding:<\/p>\n Reports reading before bed<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n What do you usually do before bed?<\/p>\n Finding:<\/p>\n Reports no screen use (television or computer) before bed<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you watch television or use the computer before bed?<\/p>\n Finding:<\/p>\n Reports average wake time of 8 AM<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n When do you usually wake up?<\/p>\n Finding:<\/p>\n Reports sleeping an average of 4 or 5 hours a night<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How many hours of sleep do you get a night?<\/p>\n Finding:<\/p>\n Reports sleeping alone in a quiet room<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Can you describe where you sleep?<\/p>\n Finding:<\/p>\n Asked about stress quality<\/p>\n Finding:<\/p>\n Reports feeling nervous and worrying about the future, with racing thoughts<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How do you feel when you are stressed?<\/p>\n Medical History<\/strong><\/p>\n Finding:<\/p>\n Confirmed use of medications<\/p>\n Finding:<\/p>\n Confirms medications (no new medications reported)<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Are you taking any new medications?<\/p>\n Finding:<\/p>\n Followed up about sleep medication use<\/p>\n Finding:<\/p>\n Denies taking OTC sleep medications<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you been taking over the counter medications to help you sleep?<\/p>\n Finding:<\/p>\n Denies taking prescription sleep medications<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you been taking prescribed medication to help you sleep?<\/p>\n Finding:<\/p>\n Confirmed allergies<\/p>\n Finding:<\/p>\n Confirms allergies (no new allergies reported)<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you had any new allergies?<\/p>\n Finding:<\/p>\n Asked about history of sleep problems<\/p>\n Finding:<\/p>\n Reports usually falls asleep very easily and “sleeps like a log”<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have a history of sleep problems?<\/p>\n Finding:<\/p>\n Reports only past sleep problems occurred for a few months after her father died, but they resolved on their own<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you had difficulty falling asleep before?<\/p>\n Psychological History<\/strong><\/p>\n Finding:<\/p>\n Asked about history of psychiatric illness<\/p>\n Finding:<\/p>\n Denies history of depression<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you ever had depression?<\/p>\n Finding:<\/p>\n Denies history of anxiety<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have a history of anxiety?<\/p>\n Finding:<\/p>\n Denies current psychiatric illness<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have a psychiatric illness?<\/p>\n Finding:<\/p>\n Denies history of psychiatric illness<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have a history of psychiatric illness?<\/p>\n Finding:<\/p>\n Denies bipolar disorder<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have bipolar disorder?<\/p>\n Finding:<\/p>\n Denies schizophrenia<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have schizophrenia?<\/p>\n Finding:<\/p>\n Denies obsessive compulsive disorder<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have obsessive compulsive disorder?<\/p>\n Finding:<\/p>\n Denies past psychiatric treatment<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have a history of psychiatric illness?<\/p>\n Finding:<\/p>\n Denies past psychotropic medications<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you ever taken psychotropic medication?<\/p>\n Finding:<\/p>\n Asked about symptoms to determine depression risk<\/p>\n Finding:<\/p>\n Reports belief she does not have depression symptoms<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have symptoms of depression?<\/p>\n Finding:<\/p>\n Reports no difficulty making decisions<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have difficulty making decisions?<\/p>\n Finding:<\/p>\n Reports slightly decreased energy due to lack of sleep<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you had less energy than usual?<\/p>\n Finding:<\/p>\n Denies feelings of guilt or worthlessness<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you been feeling guilty for no reason?<\/p>\n Finding:<\/p>\n Denies feelings of hopelessness<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you been feeling hopeless?<\/p>\n Finding:<\/p>\n Denies loss of enjoyment in activities usually found enjoyable<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you had trouble enjoying your usual activities?<\/p>\n Finding:<\/p>\n Reports slightly less appetite because she feels “a little queasy” from lack of sleep<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you had a change in appetite?<\/p>\n Finding:<\/p>\n Denies feelings of sadness<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you been feeling sad?<\/p>\n Finding:<\/p>\n Asked about suicidal tendencies<\/p>\n Finding:<\/p>\n Denies suicidal thoughts<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you ever had suicidal thoughts?<\/p>\n Finding:<\/p>\n Denies suicidal behaviors<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you ever done something that could end your life?<\/p>\n Finding:<\/p>\n Denies past suicide attempts<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you attempted suicide in the past?<\/p>\n Finding:<\/p>\n Asked about self-harm<\/p>\n Finding:<\/p>\n Denies history of self-harm<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you ever intentionally hurt yourself?<\/p>\n Finding:<\/p>\n Asked about past trauma<\/p>\n Finding:<\/p>\n Denies past trauma<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you ever had repeated, disturbing memories of a stressful experience from the past?<\/p>\n Finding:<\/p>\n Asked about history of violent thoughts<\/p>\n Finding:<\/p>\n Denies angry outbursts<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you ever had angry outbursts?<\/p>\n Finding:<\/p>\n Denies past violent behavior<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you ever behaved violently?<\/p>\n Finding:<\/p>\n Denies desire to harm others<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you ever wanted to hurt someone else?<\/p>\n Social History – Education and Work<\/strong><\/p>\n Finding:<\/p>\n Asked about employment status<\/p>\n Finding:<\/p>\n Currently employed<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Are you employed?<\/p>\n Finding:<\/p>\n Works for a shipping company<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Where do you work?<\/p>\n Finding:<\/p>\n Works 32 hours a week<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How many hours a week do you work?<\/p>\n Finding:<\/p>\n Reports rarely missing work<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n How often do you miss work?<\/p>\n Finding:<\/p>\n Asked about education and learning ability<\/p>\n Finding:<\/p>\n About to receive B.A. in Accounting<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n What is your highest education level?<\/p>\n Finding:<\/p>\n Denies past special education courses<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Did you ever take special education classes?<\/p>\n Finding:<\/p>\n Denies learning disabilities<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have any learning differences?<\/p>\n Finding:<\/p>\n Denies speech problems<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have difficulties with speech?<\/p>\n Finding:<\/p>\n Denies hearing problems<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you have hearing difficulties?<\/p>\n Finding:<\/p>\n Asked about hobbies<\/p>\n Finding:<\/p>\n Hobbies are reading and watching television<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n What do you do for fun?<\/p>\n Finding:<\/p>\n Asked about legal history<\/p>\n Finding:<\/p>\n Denies past legal issues<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you ever had a legal problem?<\/p>\n Finding:<\/p>\n Asked about military service<\/p>\n Finding:<\/p>\n Denies military service<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Have you served in the military?<\/p>\n Social History – Housing and Support Network<\/strong><\/p>\n Finding:<\/p>\n Asked about living situation<\/p>\n Finding:<\/p>\n Lives in a house<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Can you tell me about your housing?<\/p>\n Finding:<\/p>\n Lives at home with mother and sister<\/p>\n (Available)<\/p>\n 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.<\/p>\n Example Question:<\/p>\n Do you live with anyone?<\/p>\n Finding:<\/p>\n Asked about family dynamics<\/p>\n\n
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