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 Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Lifespan Review Questions Self-Reﬂection Documentation / Electronic Health Record This study resource was shared via CourseHero.com
6/6/2018 Mental Health | Completed | Shadow Health 2/4 Student Documentation Student Documentation Model Documentation Model Documentation future, diﬃculty concentrating, restlessness before bed, increased irritability. denies panic attacks for sense of impending doom. The loss of sleep and anxiety is interfering with your daily life. The stress anxiety and loss of sleep is not preventing her from her usual activities. Reports reading before bed, denies any screen use prior to bed. Actually doesn't fall asleep until 2 or 3 AM, average 4 to 5 hours a night, and wait at 8 a.m. Also reports sleeping alone in a quiet room Reports feeling stressed about the future, employment and finding a place to live. Report ways of coping with stress by going to church, staying organized, talking with family and friends, but mostly now the usual stress techniques are not working. Feeling nervous and worried about the future with racing. thoughts. Medical Hx: Diabetes Type 2 Asthma Right foot wound now scar to the sloe of foot. no reported new medications, denies OTC or prescribed medication to sleep. Can I see any history of sleep problems in the past, the only problems of sleep reported were after a few months her father passed away, normally falls asleep easily and "sleep like a log." Psychological History: Denies history of anxiety, depression, psychiatric illnesses, bipolar disease, schizophrenia, obsessive compulsive disorder, or denied any past psychiatric treatment or medication. Patient reports does not believe to have depressions, making diﬃcult decisions, denies any feelings of guilt or worthlessness, for hopelessness. Denies any loss of enjoyment from activities the patient does report slight loss of appetite due to lack of sleep making her feel "queasy." Patient denies any Suicidal Thoughts behaviors or past suicide attempts. Denies any self-harming. Patient reports angry outbursts, pass violent Behavior, or desire to harm otherr Medications: 1. ﬂuticasone 110 mcg 2 puffs BID 2. albuterol 90 mcg 2 puffs Q4H PRN 3. acetaminophen 500-1000 mg PO headaches 4. Ibuprofen 600 mg PO TID PRN menstraul cramps Allergies: cat, dust, PCN Social Hx: currently employed at Mid- American Copy and Ship a supervisor. Works 32 hours a week, her boss let her cut her hours to get her degree. And doesn't miss work.
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- Fall '15
- sleep disorder