9/16/21, 11:38 AM Focused Exam: Anxiety | Completed | Shadow Health

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Focused Exam: Anxiety Results | Turned In

Mental Health - ABSN - Fall 2021, NURS 481
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Overview
Subjective Data Collection: 36 of 36 (100.0%)
Transcript

Subjective Data Collection

Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
QSEN Competencies
Example Questions.
Documentation

SBAR
Category Scored Items Patient Data
Reflections
Not Scored
Student Survey Experts selected these topics as essential components A combination of open and closed questions will yi
of a strong, thorough interview with this patient. better patient data. The following details are facts o
patient's case.

Chief Complaint

Established chief complaint Reports that he felt like he was "smothering" -

sense of chest pressure
Reports feeling rapid heartbeat
Reports sweating and shivering
Reports shortness of breath

History of Present Illness

Asked about onset and duration of symptoms Reports feeling started last night
Reports feeling began at 3 am
Reports that feeling has been constant since
onset

Asked about aggravating factors of symptoms Reports that movement or anything besides
resting seems to make the symptoms worse

Asked about relieving factors of symptoms Reports trying to take deep breaths
Reports resting to try to feel calmer

Anxiety Screening

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9/16/21, 11:38 AM Focused Exam: Anxiety | Completed | Shadow Health
Asked about anxiety
Asked about restlessness
Asked about changes in sleeping habits
Asked about changes in eating habits
Asked about depression
Asked about impact of alcohol or drugs on
anxiety
Past Medical History
Asked about existing health conditions
Followed up on history of mental health
https://app.shadowhealth.com/assignment_attempts/10543010
Reports excessive worry
Reports worry frequency as occurring more days
that not
Reports excessive worry has happened for at
least the last 6 months
Reports unreasonable worry about work
Reports unreasonable worry about health
Reports occasionally feeling unable to control
worry
Reports occasional restlessness
Reports occasionally feeling "keyed up" or "on
edge"
Denies feeling easily tired
Denies problems concentrating
Reports occasional irritability
Denies muscle tension
Denies anxiety interferes with daily life
Reports trouble getting to sleep (due to worry)
Reports unsatisfying sleep
Followed up on changes in sleep habits
Denies taking sleep aids
Reports 5 - 6 hours of sleep per night
Reports taking 2 - 3 hours to fall asleep
Denies changes in eating habits
Denies depression
Denies losing interest in life
Denies feelings of worthlessness or guilt
Denies alcohol use caused failure to fulfill
responsibilities
Denies drug use caused failure to fulfill
responsibilities
Denies alcohol use placed him in a dangerous
situation
Denies drug use placed him in a dangerous
situation
Denies alcohol use resulted in arrest
Denies drug use results in arrest
Denies alcohol use caused problems with loved
ones
Denies drug use caused problems with loved
ones
Reports hypertension
Reports high cholesterol
Reports osteoarthritis
Denies past depression diagnosis
Denies past anxiety diagnosis
Denies past psychiatric admissions
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Followed up on hypertension diagnosis Diagnosed at age 47

Reports occasionally checking BP at the
pharmacy
Reports belief that BP is well-controlled
Reports typical numbers are 110/70

Followed up on high cholesterol diagnosis Diagnosed at age 45

Followed up on osteoarthritis diagnosis Diagnosed at age 46

Asked about allergies Denies general allergies

Denies environmental allergies
Denies latex allergy

Asked specifically about medication allergies Reports codeine allergy

Followed up on codeine allergy Reports reaction is nausea and vomiting

Home Medications

Asked about home medications Reports medication for hypertension

Denies medication for osteoarthritis
Reports medication for high cholesterol
Reports taking fish oil capsules
Denies taking vitamins
Denies taking herbal supplements

Followed up on last dose of home medications Reports no home meds taken today

Followed up on medication for cholesterol Reports taking atorvastatin

Reports atorvastatin dosage: 20 mg
Reports atorvastatin frequency: 1x daily
Denies atorvastatin side effects

Followed up on medication for hypertension Reports taking lisinopril

Reports lisinopril dosage: 10 mg
Reports lisinopril frequency: 1x daily
Denies lisinopril side effects

Family History

Asked about relevant family history Reports mother had high cholesterol
Reports father died of lung cancer, had
hypertension
Reports father died at age 50

Social History

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Asked about substance use Reports occasional alcohol use
Denies recent alcohol use
Denies illicit drug use
Denies taking any form of stimulant
Denies use of tobacco and nicotine products

Followed up on alcohol use Drinks on the weekends

Drinks 2 beers per day on the weekend

Asked about caffeine use Drinks coffee

Reports 2 cups of coffee every morning
Denies that anxiety is impacted by caffeine

Asked about family, support system, and living Reports being single
situation Reports living alone
Reports spending time with friends on the
weekends
Denies any spiritual activities
Reports no support system

Review of Systems

Asked about general symptoms Denies fever

Denies chills
Denies night sweats
Denies weight loss

Asked about review of systems for HEENT Reports blurry vision when he gets too worried
Denies impaired hearing

Asked about review of systems for respiratory Denies cough

Denies dyspnea on exertion
Denies wheezing

Asked about review of systems for Reports palpitations

cardiovascular Denies chest pain
Denies edema
Denies claudication

Asked about review of systems for skin, hair, and Denies changes in hair
nails Denies changes in skin
Denies pruritus or easy bruising
Denies pigmentation changes
Denies rashes

Asked about review of systems for Denies nausea

gastrointestinal Denies abdominal pain
Denies difficulty swallowing
Denies vomiting
Reports constipation
Denies diarrhea

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Asked about review of systems for Denies recent injury
musculoskeletal Denies joint pain
Denies erythema
Denies edema of joints

Asked about review of systems for neurological Reports weakness

Denies frequent headaches
Denies syncope, dizziness, fainting, or vertigo
Denies changes in coordination
Denies changes in memory
Denies recent falls

Asked about review of systems for psychological Reports recent mood changes
Denies hallucinations
Denies suicidal ideation or self-harm

Comments

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