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shadow health tina jones mental health assessment Subjective Data
shadow health tina jones mental health assessment Subjective Data
Subjective Data Collection: 44 of 44 (100.0%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Found:
Indicates an item that you found.
Available:
Indicates an item that is available to be found.
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
Finding:
Established chief complaint
 Subjective Action 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?”” data-html=”true” data-title=”Reports difficulty sleeping and “feeling nervous” (Found)” data-original-title=””>
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?
 Subjective Action 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?”” data-html=”true” data-title=”Reports seeking treatment because she has an upcoming exam and feels “too foggy to study” (Found)” data-original-title=””>
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?
 Subjective Action 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?”” data-html=”true” data-title=”Reports excessive worry and “racing thoughts” before bed (Available)” data-original-title=””>
Finding:
Reports excessive worry and “racing thoughts” before bed
(Available)
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
 Subjective Action 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?”” data-html=”true” data-title=”Reports difficulty sleeping began 3 1/2 weeks ago (Found)” data-original-title=””>
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?
 Subjective Action 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?”” data-html=”true” data-title=”Reports sleep difficulties have been occurring regularly during past 3 1/2 weeks (Found)” data-original-title=””>
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
 Subjective Action 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. Example Question: “How many nights a week do you have trouble sleeping?”” data-html=”true” data-title=”Reports difficulty sleeping at least four or five times a week (Found)” data-original-title=””>
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 case, it is important to know that she is suffering sleep disturbances for the majority of nights in a given week.
Example Question:
How many nights a week do you have trouble sleeping?
Finding:
Asked about aggravating factors
 Subjective Action 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. Example Question: “What makes it harder to sleep?”” data-html=”true” data-title=”Reports sleeping becomes more difficult when she can not redirect her thoughts from the things she is worried about (Available)” data-original-title=””>
Finding:
Reports sleeping becomes more difficult when she can not redirect her thoughts from the things she is worried about
(Available)
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.
Example Question:
What makes it harder to sleep?
 Subjective Action 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. Example Question: “Do you take naps?”” data-html=”true” data-title=”Denies naps during the day (Found)” data-original-title=””>
Finding:
Denies naps during the day
(Found)
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.
Example Question:
Do you take naps?
 Subjective Action 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. Example Question: “Do you drink caffeine?”” data-html=”true” data-title=”Reports drinking caffeine to stay alert (Available)” data-original-title=””>
Finding:
Reports drinking caffeine to stay alert
(Available)
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.
Example Question:
Do you drink caffeine?
 Subjective Action 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. Example Question: “When do you usually have your last caffeinated drink?”” data-html=”true” data-title=”Reports stopping caffeine use after 4 P.M. (Available)” data-original-title=””>
Finding:
Reports stopping caffeine use after 4 P.M.
(Available)
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.
Example Question:
When do you usually have your last caffeinated drink?
 Subjective Action 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. Example Question: “Do you drink alcohol before bed?”” data-html=”true” data-title=”Denies alcohol use before bed (Available)” data-original-title=””>
Finding:
Denies alcohol use before bed
(Available)
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.
Example Question:
Do you drink alcohol before bed?
 Subjective Action 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. Example Question: “Do you use drugs before bed?”” data-html=”true” data-title=”Denies drug use before bed (Available)” data-original-title=””>
Finding:
Denies drug use before bed
(Available)
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.
Example Question:
Do you use drugs before bed?
 Subjective Action 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. Example Question: “Do you think your sleep problems could be due to breathing issues?”” data-html=”true” data-title=”Reports respiratory problems are controlled and not interfering with sleep (Available)” data-original-title=””>
Finding:
Reports respiratory problems are controlled and not interfering with sleep
(Available)
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.
Example Question:
Do you think your sleep problems could be due to breathing issues?
Finding:
Asked about relieving factors
 Subjective Action 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. Example Question: “What helps you sleep?”” data-html=”true” data-title=”Reports sleeping more easily if she can distract herself from her “racing thoughts” (Found)” data-original-title=””>
Finding:
Reports sleeping more easily if she can distract herself from her “racing thoughts”
(Found)
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.
Example Question:
What helps you sleep?
 Subjective Action 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. Example Question: “Do you exercise?”” data-html=”true” data-title=”Reports no exercise (Found)” data-original-title=””>
Finding:
Reports no exercise
(Found)
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.
Example Question:
Do you exercise?
Finding:
Asked about impact of sleeping problems on daily living
 Subjective Action 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. Example Question: “How does your lack of sleep affect your daily life?”” data-html=”true” data-title=”Reports feeling tired and “out of it” most of the time during the day due to lack of sleep (Found)” data-original-title=””>
Finding:
Reports feeling tired and “out of it” most of the time during the day due to lack of sleep
(Found)
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.
Example Question:
How does your lack of sleep affect your daily life?
 Subjective Action 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. Example Question: “Have you been falling asleep when you didn’t mean to?”” data-html=”true” data-title=”Reports no increased chance of drifting off during the day despite lack of sleep (Found)” data-original-title=””>
Finding:
Reports no increased chance of drifting off during the day despite lack of sleep
(Found)
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.
Example Question:
Have you been falling asleep when you didn’t mean to?
Finding:
Followed up about patient’s experience feeling “out of it”
 Subjective Action 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. Example Question: “What do you mean when you say you feel out of it?”” data-html=”true” data-title=”Reports feeling slowed down and tired, having trouble focusing, and generally feeling “less sharp” (Found)” data-original-title=””>
Finding:
Reports feeling slowed down and tired, having trouble focusing, and generally feeling “less sharp”
(Found)
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.
Example Question:
What do you mean when you say you feel out of it?
Finding:
Asked about anxiety symptoms
 Subjective Action 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. Example Question: “Can you tell me about how your anxiety feels?”” data-html=”true” data-title=”Reports feelings of anxiety as “thoughts she can’t turn off” and “being on edge” (Available)” data-original-title=””>
Finding:
Reports feelings of anxiety as “thoughts she can’t turn off” and “being on edge”
(Available)
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.
Example Question:
Can you tell me about how your anxiety feels?
 Subjective Action 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. Example Question: “Do you ever have a sense of impending doom?”” data-html=”true” data-title=”Reports worry about the future, but no sense of impending doom (Available)” data-original-title=””>
Finding:
Reports worry about the future, but no sense of impending doom
(Available)
Pro Tip: If a patient may have anxie
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