Abigail Harris – Depression Chief Complaint Finding: Established chief complaint Finding: Reports feeling excessively weak (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: Do you feel weak? Finding: Reports fatigue and sleepiness (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: Are you fatigued? History of Present Illness Finding: Asked about onset and duration of symptoms Find ing: Reports symptoms have been happening for past month (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow -up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How often have you felt fatigued? Finding: Reports symptoms have been increasing in the past we ek (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow -up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Did the discomfort start gradually? Finding: Reports unable to get out of bed every morning (Found) Pro Tip: Asking a patient about the length of their cur rent health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow -up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Can you get out of bed? Finding: Asked about frequency, duration, and timing of symptoms Finding: Reports feeling fatigued every morning (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow -up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Exam ple Question: Are you tired in the morning? Finding: Reports feeling slightly more energetic in the afternoon (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow -up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you tired in the afternoon? Findin g: Asked about aggravating factors of symptoms Finding: Reports feeling is worse in the morning (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Detai ls of their current complaint will help you follow -up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: When do the symptoms feel worse? Finding: Reports no known t riggers (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow -up on any present conditions or sym ptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What makes your symptoms worse? Finding: Asked about treatment and relieving factors of symptoms Finding: Reports that lying down feels best when fatigued (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow -up on any present conditions or s ymptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What relieves your symptoms? Depression Screening Finding: Asked about pleasure and interest in typical activities Finding: Reports loss of in terest in typical activities (Found) Pro Tip: Screening a patient for the symptoms of depression can lead to recommendations for treatment and referrals. Depression can present with symptoms that affect sleep or appetite. These screenings can also uncover if a patient is at risk for self -harm. Example Question: Do you have little interest in doing things? Finding: Reports not taking pleasure in things that typically would (Found) Pro Tip: Screening a patient for the symptoms of depression can lead to reco mmendations for treatment and referrals. Depression can present with symptoms that affect sleep or appetite. These screenings can also uncover if a patient is at risk for self -harm. Example Question: Do you not find pleasure in things you used to like? Finding: Asked about feelings of depression Finding: Denies sadness or depression (Found) Pro Tip: Screening a patient for the symptoms of depression can lead to recommendations for treatment and referrals. Depression can present with symptoms that affect sleep or appetite. These screenings can also uncover if a patient is at risk for self -harm. Example Question: Do you feel sad or depressed? Finding: Denies feeling hopeless (Available)
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