Shadow Health Tina Jones Mental
Health Review – Advanced Health
Assessment Complete Guide
,Chief Complaint
Finding:
Established chief complaint
Finding:
Reports difficulty sleeping and "feeling nervous"
(Found)
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"
(Found)
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
(Found)
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
(Found)
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
(Found)
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
(Found)
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
Health Review – Advanced Health
Assessment Complete Guide
,Chief Complaint
Finding:
Established chief complaint
Finding:
Reports difficulty sleeping and "feeling nervous"
(Found)
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"
(Found)
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
(Found)
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
(Found)
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
(Found)
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
(Found)
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
