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Exam (elaborations)

Psychiatric Mental Health Nursing

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Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports feeling excessively weak Reports fatigue and sleepiness History of Present Illness Asked about onset and duration of symptoms Reports symptoms have been happening for past month Reports symptoms have been increasing in the past week Reports unable to get out of bed every morning Asked about frequency, duration, and timing of symptoms Reports feeling fatigued every morning Reports feeling slightly more energetic in the afternoon Subjective Data Collection: 41 of 41 (100.0%) © Shadow Health 2018 ® Focused Exam: Depression | Completed | Shadow Health 1 of 6 3/3/2019, 5:58 PM Asked about aggravating factors of symptoms Reports feeling is worse in the morning Reports no known triggers Asked about treatment and relieving factors of symptoms Reports that lying down feels best when fatigued Depression Screening Asked about pleasure and interest in typical activities Reports loss of interest in typical activities Reports not taking pleasure in things that typically would Asked about feelings of depression Denies sadness or depression Denies feeling hopeless Asked about sleep Reports light sleep Reports insomnia Reports trouble falling asleep Reports trouble staying aslee

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