Mental Health (45 min minimum) Results | Turned In
Advanced Physical Assessment Across the Lifespan (FNP) – USU – October 2021, msn572
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Subjective Data Collection: 44 of 44 (100.0%)
Chief Complaint
History of Present Illness
Your Results
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
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Category Scored Items
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Patient Data
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better patient data. The following details are facts of the
patient’s case.
Established chief complaint Reports difficulty sleeping and “feeling nervous”
Reports seeking treatment because she has an
upcoming exam and feels “too foggy to study”
Reports excessive worry and “racing thoughts”
before bed
Asked about onset and duration of symptoms Reports difficulty sleeping began 3 1/2 weeks ago
Reports sleep difficulties have been occurring
regularly during past 3 1/2 weeks
Asked about frequency of symptoms Reports difficulty sleeping at least four or five times
a week
Asked about aggravating factors Reports sleeping becomes more difficult when she
can not redirect her thoughts from the things she is
worried about
Denies naps during the day
Reports drinking caffeine to stay alert
Reports stopping caffeine use after 4 P.M.
Denies alcohol use before bed
Denies drug use before bed
Reports respiratory problems are controlled and
not interfering with sleep
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Medical History
Psychological History
Asked about relieving factors Reports sleeping more easily if she can distract
herself from her “racing thoughts”
Reports no exercise
Asked about impact of sleeping problems on daily living Reports feeling tired and “out of it” most of the time during the
day due to lack of sleep
Reports no increased chance of drifting off during the day despite
lack of sleep
Followed up about patient’s experience feeling “out of it” Reports feeling slowed down and tired, having trouble focusing,
and generally feeling “less sharp”
Asked about anxiety symptoms Reports feelings of anxiety as “thoughts she can’t turn off” and
“being on edge”
Reports worry about the future, but no sense of impending doom
Reports no panic attacks
Reports difficulty concentrating due to fatigue from lack of sleep
Reports only restlessness occurs just before bed
Reports slight irritability due to fatigue
Asked about impact of anxiety on daily living Reports stress only interferes with daily life because it interrupts
her sleep
Reports stress does not prevent her from completing her usual
activities
Asked about sleep quality Reports falling asleep often takes more than an hour
Reports waking up two or three times during the night for “at
least ten minutes”
Reports waking in the morning feeling “out of it” and not rested
Asked about sleep habits Reports going to bed “around midnight,” but feeling “too nervous”
to sleep
Reports actually falling asleep at 2 or 3 AM
Reports reading before bed
Reports no screen use (television or computer) before bed
Reports average wake time of 8 AM
Reports sleeping an average of 4 or 5 hours a night
Reports sleeping alone in a quiet room
Asked about stress quality Reports feeling nervous and worrying about the future, with
racing thoughts
Confirmed use of medications Confirms medications (no new medications reported)
Followed up about sleep medication use Denies taking OTC sleep medications
Denies taking prescription sleep medications
Confirmed allergies Confirms allergies (no new allergies reported)
Asked about history of sleep problems Reports usually falls asleep very easily and “sleeps like a log”
Reports only past sleep problems occurred for a few months
after her father died, but they resolved on their own
Asked about history of psychiatric illness Denies history of depression
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Social History – Education and Work
Social History – Housing and Support Network
Denies history of anxiety
Denies current psychiatric illness
Denies history of psychiatric illness
Denies bipolar disorder
Denies schizophrenia
Denies obsessive compulsive disorder
Denies past psychiatric treatment
Denies past psychotropic medications
Asked about symptoms to determine depression risk Reports belief she does not have depression symptoms
Reports no difficulty making decisions
Reports slightly decreased energy due to lack of sleep
Denies feelings of guilt or worthlessness
Denies feelings of hopelessness
Denies loss of enjoyment in activities usually found enjoyable
Reports slightly less appetite because she feels “a little queasy”
from lack of sleep
Denies feelings of sadness
Asked about suicidal tendencies Denies suicidal thoughts
Denies suicidal behaviors
Denies past suicide attempts
Asked about self-harm Denies history of self-harm
Asked about past trauma Denies past trauma
Asked about history of violent thoughts Denies angry outbursts
Denies past violent behavior
Denies desire to harm others
Asked about employment status Currently employed
Works for a shipping company
Works 32 hours a week
Reports rarely missing work
Asked about education and learning ability About to receive B.A. in Accounting
Denies past special education courses
Denies learning disabilities
Denies speech problems
Denies hearing problems
Asked about hobbies Hobbies are reading and watching television
Asked about legal history Denies past legal issues
Asked about military service Denies military service
Asked about living situation Lives in a house
Lives at home with mother and sister
Asked about family dynamics Has a brother and a sister
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3 of 5 12/9/2021, 8:51 PM
Social History – Substance Use
Social History – Relationship and Sexual History
Father died in a car accident almost two years ago
Reports family is “tight knit” and gets along well
Asked about support network Reports close group of friends from middle and high school as
well as from church
Spends time with friends “a few times a month,” though less so
with her recent schedule
Asked about spirituality Identifies as Baptist
Reports attending Baptist church regularly since childhood
Asked about substance use Reports past marijuana use
Denies current substance use
Followed up on past marijuana use Reports smoking marijuana for “five or six years”
Reports last smoked marijuana when she was “20 or 21” years
old
Reports quitting marijuana because it “just wasn’t fun anymore”
and was bad for her asthma
Reports marijuana use was for recreation, not to treat or mitigate
specific symptoms
Asked about alcohol use Confirms alcohol use
Reports going out “a couple times a month”
Reports having “a few drinks” when she goes out
Reports 10-12 alcoholic drinks per month
Reports drinking to “relax and blow off steam”
Denies that anyone has asked her to stop drinking
Denies guilt associated with drinking
Asked about drinking and driving Reports that she and her friends “usually take a cab”
Asked about tobacco use Denies history of tobacco use
Denies current tobacco use
Asked about prescription drug abuse Denies prescription drug abuse
Asked about relationship status Currently single
Asked about relationship history Reports past relationships
Last relationship ended three years ago
Most recent relationship lasted three years
Reports she has never been married
Asked about sexual history Reports past sexual relationships
Reports three previous sexual partners
Reports last sexual encounter was with boyfriend three years
ago
Asked about abuse history Denies history of abuse
Denies past physical abuse
Denies past verbal abuse
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4 of 5 12/9/2021, 8:51 PM
Social Determinants of Health
Family History
Asked about stress causes Reports feeling stressed about studying and the future
Reports CPA professional qualifying exam in one month
Reports upcoming graduation from college and need to secure
employment
Asked about stress coping Reports coping with stress by going to church
Reports coping with stress by staying organized
Reports coping with stress by talking to friends and family
Reports usual stress coping strategies are less effective
Asked about relevant family history Denies psychiatric illness in the family
Reports uncle has a “problem with alcohol”
Denies family history of drug addiction
Denies family history of suicide