Focused Exam: Depression Results | Turned In
Community Mental Health - Fall 2024, MTHL 9230/9246
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Overview
Transcript
Transcript
Started: Sep 26, 2024 | Total Time: 130 min
Subjective Data Collection
All Lines (188) Interview Questions (115) Statements (15) Exam Actions (58)
Objective Data Collection
Education & Empathy Greet
Hi my name is Lorna and I will be taking care of you today
09/26/24 7:22 PM EDT
QSEN Competencies
Documentation Hey.
SBAR
Question
What do you prefer I call you
Reflections 09/26/24 7:23 PM EDT
I go by Abigail.
Question
Hello Abigail what brings you in today (Clarified to What brings you in today?.)
09/26/24 7:23 PM EDT
My son brought me in today on account of my exhaustion. I've been feeling very
weak and very tired. Most mornings I don't really feel like getting out of bed.
(Clarified to why I came in.)
Can you tell me about the frequency duration and timing of your symptoms (No Question
matching questions found.) 09/26/24 7:23 PM EDT
Tell me more about your symptoms (Clarified to Can you describe your Question
symptoms in more detail?.) 09/26/24 7:24 PM EDT
I'm just so tired and weak all of the time. Even after a rare full night of sleep, I
wake up completely drained. (Clarified to if I can describe my symptoms.)
Question
How frequent is this happening
09/26/24 7:24 PM EDT
Oh, it's been a while. I can't say for certain when the last time I had one was.
Question
How long usually is the symptom last (No matching questions found.)
09/26/24 7:24 PM EDT
Question
How long usually the symptoms lasts?
09/26/24 7:25 PM EDT
I've been exhausted in the morning for almost every day for the past month. This
week I've been feeling more tired with every day. I do feel a bit more lively in the
afternoon, though.
Is there a particular time of the day this is happening (No matching questions Question
found.) 09/26/24 7:25 PM EDT
, Is there a particular time of the day the symptoms appear? (No matching questions found.)
0
What makes it worse
0
It's just an aching pain in my joints. It's gotten a little worse over the last few weeks... I haven't taken
anything for it though.
Is there anything that aggravates the symptoms
0
It's worse in the morning, I suppose but there's nothing that specifically makes me feel more tired, I just
am. From the moment I open my eyes, I'm spent.
What treatment are you using for this (No matching questions found.)
0
Have you had it treated? (No matching questions found.)
0
May I know the treatment you are using for this (No matching questions found.)
0
Is there anything you are using to treat it?
0
I take some medication to help me sleep a few times a week.
What medication are you using?
0
I have medication for my thyroid and my diabetes, along with an antidepressant. I'll take something to
help me sleep occasionally, too.
What helps relieve your symptoms?
0
All I want to do when I feel tired is just lie down. It's what feels best when I get like that.
Do you feel pleasure and interest in your typical activities
0
I don't have the energy or desire to do what used to make me happy. Going to church, getting dressed
up, spending time with friends, taking walks . . . none of that interests me recently, and I'm too fatigued
to even try. Even smaller things . . . I can't help with housework or take care of my medication on my
own. Thank goodness for my son.
Do you feel depressed
0
Well, I've been diagnosed with depression, but I wouldn't really say I feel particularly sad. I just can't
seem to get interested in anything anymore, and the more I think about it the worse I feel about myself.
Some days, I feel like I'd be better off just not waking up one morning.
I am sorry you are feeling this way
0
I'm just so tired and weak all of the time. Even after a rare full night of sleep, I wake up completely
drained.
I want you to know that what you're feeling is really important and it's completely understandable to
feel drained fatigued and weak when you're going through such a tough time 0
I'm grateful for that.
Depression can have significant impact on our energy levels on sleep patterns making everything feel
overwhelming 0
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