Professional Development

Write a 1000-word APA reflection essay of your experience with the Shadow Health virtual assignment(s). At least two scholarly sources in addition to your textbook should be utilized. Answers to the following questions may be included in your reflective essay:
What went well in your assessment?
What did not go so well? What will you change for your next assessment?
What findings did you uncover?
What questions yielded the most information? Why do you think these were effective?
What diagnostic tests would you order based on your findings?
What differential diagnoses are you currently considering?
What patient teaching were you able to complete? What additional patient teaching is needed?
Would you prescribe any medications at this point? Why or why not? If so, what?
How did your assessment demonstrate sound critical thinking and clinical decision making?
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Documentation / Electronic Health Record

Document: Provider Notes

Student Documentation Model Documentation

Your Results Lab Pass (/assignment_attempts/6690008/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Document: Provider Notes

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Student Documentation Model Documentation

Subjective

Ms. Tina Jones is a 28yo pleasant AA female. She is alert, well- groomed. Speech is fluent and words are clear. Thought process are coherent, insight is good. She maintaines eye contact during our interview. She presents to the clinic c/o difficult sleeping this past month, and is occuring more often this past 3 1/2 weeks. She reports feeling “nervous, excessive working before bedtime” She feels “on edge” due to lack of sleep. She sleeps an average fo 4-5 hours, and is awake by 8am. She sleeps like a “log” when she has fallen asleep. She watches tv and reads book to assist with her sleep. She does not take naps. She drinks four diet coke daily, last intake at 4pm. Social Hx: stress in her life, due to upcoming exams and job search after graduation. She has support from her family, friends and her church members whom she sees twice a week. Father passed away, felt sad, and is coping well. No counseling, but felt she did not need one for her griefing process. Drug use: hx of thc use at 20 years old: stopped. No tobacco use. ETOH: socially. She does not exercise, for she gets tired with work and school. No medications used for insomnia. ROS: Loss of appetite, probably due to her feeling tired. Has increase fatigue in the daytime. Has changes in concentration due to fatigue. PMHX: Diabetes: no meds Asthma: on albuterol and proventil : controlled asthma Mental health: denies depression, sucidal thoughts or homicidal ideation. no hx of anxiety except for today due to upcoming exams and future job searc. Does feel her mood has been “off” and does not feel like herself. She denies tension or memory loss. Family hx: No mental illness, only Uncle with alcoholism.

HPI: Ms. Jones presents to the clinic complaining of difficulty sleeping which she notes to have started 1 month ago. She state that her sleep is “shallow and not restful”. She complains of diffic falling asleep at least 4 or 5 nights per week, but states that she able to stay asleep without difficulty. On average she sleeps 4 or hours per night and awakens at 8:00am daily. She states that she has a fairly consistent schedule on weekdays and weekends. Sh does not take any prescription or over the counter sleep aids. Sh limits screen time prior to bed and does not ingest caffeine after 4pm daily. She endorses decreased feelings of sleepiness over t past month. She denies difficulties awaking, but does not feel res in the morning and has daytime fatigue (rates 5/10 severity), restlessness, and irritability (rates 2/10 severity). She does not ta naps. Social History: She states that she has some stress related to he upcoming examinations and her impending job search upon graduation. She states that she has a strong support system ma up of friends and family and she is active in her church. She state that she copes with stress by staying organized. She enjoys read 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 that time as well. She denies use of tobacco. She drinks approximately 10-12 alcoholic beverages per month, but never m than 3 per sitting and does not note any impact on her sleep. Sh has used marijuana in the past, but no current use and denies ot illicit drugs. She does not exercise regularly, but states that her jo somewhat active and she walks 5-15 minutes daily. She drinks 1 diet colas per day. Family History: Denies any history of known sleep disorders or psychiatric disorders. Review of Systems: • General: Denies changes in weight, weakness, fever, chills, and night sweats. Does complain of increasing daytime fatigue. • Neurologic: Denies loss of sensation, numbness, tingling, tremo weakness, paralysis, fainting, blackouts, or seizures. Endorses changes in concentration and sleep. Denies changes or difficultie coordination. • Psychiatric: States that her mood has been “off” and she does feel like herself. She does complain of increased anxiety related t upcoming exams and job search. She has no history of depressi but does state that she feels helpless and notes that her performance at work and school is beginning to decline. She den tension or memory loss. No past suicide attempts. Denies suicid homicidal ideation.

Assessment

Insomnia related to anxiety Sleep disturbance related to anxiety

Student Documentation Model Documentation

Plan

Encourage a diary of her episodes of insomnia and anxiety: stating associated factors and what helps with the anxiety Offer cognitive behavioral therapy (CBT) Educate on anxiety reduction strageties including deep breating, relaxation and guided imagery. Offer consultation to behavioral Health Specialist Encourage diet and exercise regimin Decrease caffeine intake Offer telephone appointment to check in with her in a week Give warning signs on when to seek for help, as in inability to care for self, depression, anxiety or sucidal ithoughts.

• Encourage Ms. Jones to continue to monitor symptoms and log episodes of insomnia and anxiety with associated factors and br log to next visit. • Encourage to decrease caffeine consumption and increase inta of water and other fluids. • Educate on anxiety reduction strategies including deep breathin relaxation, and guided imagery. Continue to monitor and explore need for possible referral to social work/psychiatry or pharmacol intervention. • Discuss need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2pm, limiting fluids after dinner, limiting screen time or stimulating activities after 8pm, and to get out of bed if awaken in the middle the night. • Educate to limit alcohol and depressant medications (including diphenhydramine and Tylenol PM). • Educate on when to seek further or emergent care including feelings of self-harm or hopelessness. • Revisit clinic in 2-4 weeks for follow up and evaluation.

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Mental Health Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1

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Transcript

Started: Apr 20, 2020 | Total Time: 77 min

Gree 04/20/20 6:52 PM MD

Question 04/20/20 6:52 PM MD

Empathize 04/20/20 6:53 PM MD

Question 04/20/20 6:54 PM MD

Empathize 04/20/20 6:55 PM MD

Your Results Lab Pass (/assignment_attempts/6690008/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Interview Questions (116) Statements (34) Exam Actions (0)

Hello Miss Jones my name is Doris and it’s good to see you again

Hey.

How are you doing today

I’m not doing too great, honestly. I’ve been feeling nervous before bed and having a lot of trouble sleeping lately.

I’m sorry that must be difficult for you I’m happy that you’re here today to talk about it

I appreciate you saying that.

Is that what brings you here today

I decided to come in because I’m tired all the time now. . . I have this really important exam coming up, and I’m stressed and too foggy to study most of the time. I really need help sleeping so I can focus on preparing for my exam.

How long have you had trouble sleeping

This all started almost a month ago. . . it’s been happening regularly for about three and a half weeks, I’d say.

I’m sorry you must be feeling really tired

Thanks.

All Lines (150)

Question 04/20/20 6:56 PM MD

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Have you had this problem before

Well. . . the only other time I’ve had sleep problems was right after Dad died. It felt a little like this, with my mind racing, but honestly, not as bad. Other than that month or two, I’ve always been a really good sleeper. I could fall asleep right away, and then I’d sleep like a log.

Can you describe what your feeling before you go to bed

It’s like. . . once it gets close to bed time, I start feeling on edge, even though I’ve been pretty tired all day. Then once the light’s off and I try to sleep, my mind just starts racing, and I think about all the things in the future that I’m stressed out about.

I’m sorry to hear that

I appreciate you telling me that.

Is there anything that AGGRAVATES THESE SYMPTOMS

Basically, the more I think about what I’m worried about, the worse it is. Sometimes I can distract myself and not let myself start thinking about all the things that stress me out, but that’s been rare.

Is there something that makes it better

Basically the only way I get to sleep easily is if I manage to feel less stressed out–sometimes I can sort of turn my thoughts away from what I’m worried about by distracting myself with something, like thinking about what I’m going to wear the next day or something like that. I’d rather avoid having to take medication if possible. Taking deep breaths can help a little, too.

Is there any other symptoms that happens with difficult sleeping (Clarified to What about other symptoms?.)

When I feel anxious, it’s like. . . I’m kind of on edge and nervous, and my thoughts start racing, and I just think about all the things there are to worry about. (Clarified to what other symptoms I have.)

Have you had any medication for this before (No matching questions found.)

Have you ever had anxiety before

Lately I’ve felt pretty anxious, I guess. . . mostly right before bed. I just feel on edge, and like my thoughts can’t turn off when I want them to.

Do you take naps in the day

I’m not really a big nap person–if I fall asleep, I want to sleep for hours, not wake up in twenty minutes feeling groggy. Plus I don’t have time for them, anyway.

Do you drink a lot of caffeine

Question 04/20/20 6:59 PM MD

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Honestly, I know I have to limit my caffeine, especially since I’m having trouble sleeping, but I feel so foggy during the day that I really need something to wake me up, so I’ve been having a few diet Cokes over the course of the morning.

Can I ask how many coats do you get a day (No matching questions found.)

HOW MANY COKES DO YOU DRINK IN A DAY

I drink maybe four diet sodas a day.

What time is the last time you drink Coke

I know it’s bad to drink too much caffeine, especially when you’re having sleep problems, so I try not to drink it after the morning. I definitely never have any diet Cokes after 4 PM at the latest.

Do you drink any alcohol

I do sometimes, yeah, when I go out with my friends.

How often do you go out with your friends

I see my friends pretty often–I’ll go out with my girls once a week or so, and I see friends at church too.

Hanging out with friends can help you with your stress

Sure, I think I understand what you mean.

Your church friends must be very supportive

Thanks for telling me.

Do you take illicit drugs

No.

I’m sorry to hear about your father

Thanks for understanding.

Have you had any counseling after your father passed away (No matching questions found.)

Have you had any counseling for depression

I don’t think I’m depressed.

Question 04/20/20 7:02 PM MD

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Were you depressed when your father passed away (Clarified to Did you get depressed after your dad died?.)

I wouldn’t say I was depressed–I know that’s really serious. I was just sad and grieving. It was really hard, but over time, it got better. I miss him every day, but I know God is taking care of him. (Clarified to if I got depressed after my dad died.)

It is normal to be sad when A LOVED ONE PASSES, I am happy you were able to handle that

Alright, thanks for letting me know.

Do you have any trouble breathing when you’re trying to fall asleep (Clarified to Do you have trouble breathing at night?.)

My breathing has been fine since I started the daily inhaler, actually. (Clarified to if I have trouble breathing at night.)

Can you tell me your medical history

I’ve had asthma since I was little, and I have sugar diabetes, too.

Are you taking medication for your asthma

I just use my inhaler.

How often are you using your inhaler

Yeah. Two puffs, twice a day. I’ve been good about taking all my doses.

What is the name of your medication (Clarified to What medications do you take?.)

All I have is a Proventil inhaler and a Flovent inhaler for my asthma. (Clarified to what medications I am taking.)

When was your last asthma attack

Well, I use my daily inhaler every day. I haven’t had to use my rescue inhaler in maybe nine months.

Have you ever been hospitalized for asthma

I went a bunch of times when I was little, for asthma attacks.

Are you taking medication for diabetes

I don’t take anything for my diabetes anymore.

Your diabetes must be under control that’s good news

Question 04/20/20 7:05 PM MD

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OK, I understand.

Do you exercise

I just don’t have time to exercise, honestly.

How does difficulty sleeping have an impact on your daily activities (No matching questions found.)

does your difficult sleeping impact your daily activities

Well. . . I’m tired all day, and I feel kind of out of it. That makes it hard to focus and get things done, especially when I try to study for my exam coming up. It’s pretty frustrating.

Do you drift off to sleep in the middle of the day

No, though I do feel groggy during the day.

That must be very difficult for you I’m sorry to hear that

Thanks for saying that.

What do you mean by being out of it

It’s like. . . I just feel slowed down and tired all the time from not sleeping. It’s harder to focus, or get things done efficiently. . . I’m just generally less sharp.

I must be very difficult for you

I appreciate you saying that.

Do you have any anxiety or thoughts that you can’t turn off (No matching questions found.)

do you have thoughts that you can’t turn off (Clarified to Have you ever had thoughts of suicide?.)

No, never. (Clarified to if I have ever thought about suicide.)

When you’re worried do you feel impending doom (Clarified to Do you ever have a sense of impending doom?.)

No, I don’t feel doomed, just worried about stuff, especially not being able to sleep when there’s so much to do. (Clarified to if I ever have a sense of impending doom.)

Panic attacks (Clarified to Have you ever had a panic attack?.)

I’ve never had a panic attack, no. (Clarified to if I have ever had a panic attack.)

Question 04/20/20 7:09 PM MD

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Do you have trouble concentrating do to your fatigue (Clarified to How often are you having trouble concentrating?.)

Ever since these sleep problems started, I notice some trouble concentrating. I feel a little out of it sometimes. (Clarified to how often I have difficulty focusing.)

That must be really hard on you sorry to hear that

Thanks for understanding.

Do you feel irritable

I feel like little setbacks annoy me more since my sleep trouble started. . . like if I can’t find my keys, or I get stuck at a red light, it’s harder for me to be patient about it.

Tell me more about your stress

When I feel anxious, it’s like. . . I’m kind of on edge and nervous, and my thoughts start racing, and I just think about all the things there are to worry about.

What are you worried about

Mostly I start out worrying about this exam I have coming up, and how much I need to study, and then I start thinking about what happens if I don’t pass the exam, and even if I do, whether I’ll actually be able to find an accounting job once I graduate, and then if I do find a job, what if I’m bad at it. . . it just sort of builds on itself like that, just, like, worry upon worry.

Can totally understand where you’re coming from I am sorry that you are worried about the future

Thanks for saying that.

It might help to start up just taking one day at a time

That makes sense.

It might be good to have a goal task daily

OK, I understand.

Does stress prevent you from completing your activities

Being anxious is mostly just interfering with my sleep, and then not being able to get enough sleep is interfering with my life.

How is it interfering with your life (No matching questions found.)

When you fall asleep how long do you sleep (Clarified to What time do you fall asleep?.)

Question 04/20/20 7:13 PM MD

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Question 04/20/20 7:15 PM MD

I get into bed around midnight, but then I’ll read because I can feel myself start to stress about stuff and I need a distraction. So I’ll actually turn of the light and close my eyes around 1 or so, and then I won’t fall all the way asleep for another hour and a half, two hours, usually. Sometimes, if I really start stressing out, I’ll even turn the light back on and read more until I feel more wound down. (Clarified to when I usually go to sleep.)

How much sleep do you get a night

Not much. . . 4 or 5 hours a night, usually.

Can you describe your sleep habits

Well. . . I usually get into bed around midnight, but at that point I feel too nervous to sleep, so I’ll read to try and wind down for maybe an hour, sometimes longer. Then I turn out the light and try to sleep. If it takes a really long time, then sometimes I’ll turn the light back on and read a little more until I feel sleepier.

What time do you wake up in the morning

I have to be out of bed by 8 every morning.

Do you sleep alone

Yep. [AUDIO COMING SOON]

Do you do anything to cope with stress (Clarified to How do you cope with stress?.)

Usually I try to stay organized, you know, make to-do lists, plan my time, that kind of thing. Sometimes I’ll talk to friends or family. . . going to church usually helps, too. Lately, though, none of that is really helping like it should. (Clarified to how I cope with stress.)

I’m so sorry to hear that

Thanks.

Friends are very important in helping you cope with stress

Thanks for telling me.

Do you take medication for stress

No, luckily I’ve never needed that.

Are you allergic to any medication

Yeah, I’m allergic to penicillin.

What happens if penicillin (Clarified to What type of reaction do you have to penicillin?.)

Educate 04/20/20 7:16 PM MD

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I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that. (Clarified to what my reaction to penicillin is.)

I’m glad to know that you know your allergy to penicillin

Alright, thanks for letting me know.

Do you take over the counter medication for stress (Clarified to Have you been taking over the counter sleep medications?.)

No, I haven’t tried taking anything to sleep. I’d rather avoid having to take medication if possible. (Clarified to if I have been taking over the counter sleep medication.)

Do you take any over-the-counter medication

I take Tylenol for a headache sometimes, or Advil for cramps, but not often.

Have you had any psychiatric illness

My mental health has always been fine, fortunately.

Do you have any bipolar disorder

No.

Do you have any schizophrenia

No, I don’t.

Do you have any obsessive compulsive disorder

No. I feel really lucky that I haven’t had to deal with that.

Have you ever had any psychiatric treatment (Clarified to Do you have a history of psychiatric treatment?.)

I’ve never needed to see a therapist or anything. (Clarified to if I have a history of psychiatric treatment.)

Have you had any mental illness

My mental health has always been fine, fortunately.

Are you able to make decisions

No. I know I probably should, but that kind of thing just feels really morbid to me.

Question 04/20/20 7:18 PM MD

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Do you ever feel guilty or worthlessness

I really try hard not to do anything I would feel guilty about, and it works–I don’t really ever feel guilty about anything. And if I do, I pray on it.

Mental health is an important part of our well-being

Sure, I think I understand what you mean.

Have you ever felt hopelessness

I don’t feel hopeless, just frustrated and stressed out.

Do you find your job enjoyable

I like my job, especially since being promoted to shift supervisor. I like the people I work with . . . and I can see myself moving up when I finish my degree.

That’s good to hear I’m proud of you

I appreciate you telling me that.

Do you have decreased appetite

I’m feeling less hungry lately, actually. . . I think not sleeping is making me feel a little queasy during the day.

Have you had a change of weight

I think I have maybe lost a couple pounds, but nothing major. Maybe like two or three.

Were you trying to lose weight (Clarified to Are you trying to lose weight?.)

Honestly, I don’t really have time to exercise, and even if I did, I wouldn’t be doing it to lose weight. I don’t think about my weight much at all. (Clarified to if I am trying to lose weight.)

Do you feel sad most of the time

I’m not really feeling sad. . . more just stressed out.

Do you have any Suicidal Thoughts

No, never.

Have you had a history of suicidal thoughts

Question 04/20/20 7:21 PM MD

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No, never.

Do you have suicidal behaviors

I don’t like to take real risks. Especially after Dad’s accident, I try to treat life like a gift. I’m not going to throw it away doing something stupid.

That’s really good to hear Miss Jones, life is precious

That makes sense.

Do you feel you want to harm yourself

No, I’ve never wanted to hurt myself.

Have you had any trauma in the past (Clarified to Have you had traumatic memories?.)

No, not really. (Clarified to if I have had traumatic memories.)

Do you have any angry outburst

I don’t really get angry a lot. I try to be patient with people. . . it just makes everything easier that way.

That’s great to hear Tina

Thanks for telling me.

How many hours do you work in a week

I work about thirty two hours a week right now, sometimes a little more if things are busy. I used to be full-time, but my bosses let me cut my hours a bit so that I could get my degree at the same time.

That’s great to hear Tina

Sure, I think I understand what you mean.

Your boss is an understanding person and I’m happy to hear that

Thanks.

Do you ever miss work

I’ve still been going to work. . . it’s just harder to get things done while I’m there because I haven’t been getting enough sleep.

Question 04/20/20 7:24 PM MD

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Do you have any learning disabilities

No.

Do you have any speech problems

No. I might stumble over my words sometimes but nothing like that.

Do you have any hearing problems

No.

Are you having trouble in school (Clarified to Do you have trouble with school work?.)

Only lately because of my sleep problems–I can do it, but I just don’t feel like myself. I’m not rested, and I’m kind of out of it. (Clarified to if I have trouble with school work.)

That must really be hard Tina I’m sorry to hear that

I appreciate you telling me that.

Do you have any hobbies

I read a lot, especially since I bought one of those e-book readers. My friends and I have thought about starting a book club actually. Oh, and there’s these free talks at church that I like to go to if I have time. I watch TV, but usually on DVD or streaming. I like to marathon the shows I really like. I’m really interested in documentaries, too.

It’s good to hear that you’re reading a lot and that you have time for that

That makes sense.

Do you live alone

I live at home with my mom and my sister.

Must be good to have them around

Alright, thanks for letting me know.

Do you get along well with your family

Things are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along.

That’s great to hear

Educate 04/20/20 7:27 PM MD

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OK, I understand.

Family is important

Sure, I think I understand what you mean.

Do you have a group of friends you hang out with (Clarified to How often do you see your friends?.)

Usually I see my friends a few times a month. . . But other than seeing my church friends on Sundays and Wednesdays, at Bible study, I haven’t been able to do much the past few weeks. I just have too much stuff to do. (Clarified to how often I see my friends.)

It must really be hard to find time with with friends when you’re busy

Thanks for understanding.

Taking illicit drugs

No.

Have you ever smoked marijuana

Well, I used to smoke pot. . . but I don’t do that anymore.

How long ago was the last time you smoked (Clarified to When did you stop smoking marijuana?.)

About. . . eight years ago? I think I was twenty or twenty one when I stopped. (Clarified to when I stopped smoking pot.)

What did marijuana do to you

Yeah, for a while there I did it a lot, probably every weekend. But I haven’t in a long time.

That’s good to hear Tina

Thanks for telling me.

Smoking can make your asthma worse so it’s good to hear that you’re not doing that

Alright, thanks for letting me know.

You mentioned that you drink with your friends how do you get home after that (No matching questions found.)

When you drink with your friends do you drive

Educate 04/20/20 7:31 PM MD

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Uh. . . I guess a friend might drive if she’s had only a couple of drinks.

studies have shown that drinking even the minimum amount of alcohol can affect your driving

OK, I understand.

Guilty drinking

I wouldn’t say I feel guilty about it, no.

Do you smoke tobacco

No, never.

Do you smoke e cigarette

No. I think it’s gross.

Are you in a relationship

No, I’m not in a relationship right now.

How long ago has it been you been in a relationship

I broke up with my last boyfriend about three years ago.

Was that difficult to you (No matching questions found.)

Was that difficult to you when you broke up (No matching questions found.)

were you okay when you broke up with your boyfriend

No, I’m not in a relationship right now.

Are you sexually active

No, I haven’t been in a while.

How many partners have you had in the past

I have had four boyfriends, and I’ve had sex with three of them.

Did you use any barrier method

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I used to be on the pill.

Condoms is the best barre method when you’re having sex to prevent sexual transmitted disease

That makes sense.

Have you ever been abused

No, never.

Have you ever had verbal abuse

No one’s ever done that to me, no.

Any physical abuse

I’ve never been hurt like that, luckily.

That’s great to hear Tina

Sure, I think I understand what you mean.

Have you have any psychiatric illness in your family (Clarified to Do you have a history of psychiatric illness?.)

No. (Clarified to if I have a history of psychiatric illness.)

Do you have a family history of psychiatric illness

No. They’re crazy, but nobody’s diagnosed with anything.

Do you have any family history of drug addiction

None that I know of.

Do you have a family history of alcohol abuse

My uncle, my dad’s brother, has an alcohol problem, but we never see him anymore.

Is he still alive

No, Nana died five years ago.

Do you have any family history of suicidal

Question 04/20/20 7:36 PM MD

Question 04/20/20 8:00 PM MD

Question 04/20/20 8:01 PM MD

No one in my family has done that, thankfully.

Is there anything you want to tell me that I didn’t ask (Clarified to Is there anything about your mental status you want me to know?.)

Other than stress and this sleep thing I think my mental status is fine. . . (Clarified to if there’s anything about my mental status I want you to know.)

Is there anything you want to tell me that I didn’t ask (Clarified to Is there anything else you think I should know?.)

If you think I’ve covered it, then I guess we’re good. (Clarified to if there is anything else you should know.)

Why do you have trouble sleeping

Show stress (Clarified to What does stress feel like to you?.)

Usually when I’m stressed I just get kind of scattered and distracted, so if I stay organized, I’m fine. Lately, though, it’s just these racing thoughts of everything I’m worried about, and it’s harder to control. (Clarified to what stress feels like.)

Is stress taking over your life

I guess, like, right this moment life isn’t that stressful. . . it’s more all the stuff coming up that I’m worried about.

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