Subjective

Ms. Tina Jones is a 28yo pleasant AA female. She is alert, well- groomed. Speech is fluent and words are clear. Thought processes are coherent, and insight is good. She maintained eye contact during our interview. She presents to the clinic c/o difficult sleeping this past month which is occurring 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 of 4-5 hours and is awake by 8 am. She sleeps like a “log” when she has fallen asleep. She watches tv and reads books to assist with her sleep. She does not take naps. She drinks four diet coke daily, the last intake at 4 pm. 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 grieving process. Drug use: hx of the use at 20 years old: stopped. No tobacco use. ETOH: socially. She does not exercise, for she gets tired of work and school. No medications are used for insomnia. ROS: Loss of appetite, probably due to her feeling tired. Has increased 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, suicidal thoughts, or homicidal ideation. no hx of anxiety except for today due to upcoming exams and future job searches. 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 states that her sleep is “shallow and not restful”. She complains of difficulties falling asleep at least 4 or 5 nights per week but states that she is able to stay asleep without difficulty. On average she sleeps 4 for hours per night and awakens at 8:00 am daily. She states that she has a fairly consistent schedule on weekdays and weekends. She does not take any prescription or over-the-counter sleep aids. Sh limits screen time prior to bed and does not ingest caffeine after 4 pm daily. She endorses decreased feelings of sleepiness over t past month. She denies difficulties waking, 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 nap. Social History: She states that she has some stress related to the 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 states that she copes with stress by staying organized. She enjoys reading 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 at that time as well. She denies the 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. She has used marijuana in the past, but has no current use and denies illicit drugs. She does not exercise regularly but states that she’s somewhat active and walks 5-15 minutes daily. She drinks 1 diet of cola 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, tremors weakness, paralysis, fainting, blackouts, or seizures. Endorses changes in concentration and sleep. Denies changes or difficulty coordinating.

• 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 searches. She has no history of depression but does state that she feels helpless and notes that her performance at work and school is beginning to decline. She denies tension or memory loss. No past suicide attempts. Denies suicide or 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 strategies including deep breathing, relaxation, and guided imagery. Offer consultation to behavioral Health Specialist Encourage diet and exercise regimen Decrease caffeine intake Offer telephone appointment to check in with her in a week Give warning signs on when to seek help, as in inability to care for self, depression, anxiety, or suicidal thoughts.

• Encourage Ms. Jones to continue to monitor symptoms and log episodes of insomnia and anxiety with associated factors and log to the next visit.

• Encourage to decrease caffeine consumption and increase intake of water and other fluids.

• Educate on anxiety reduction strategies including deep breathing relaxation, and guided imagery. Continue to monitor and explore the need for possible referral to social work/psychiatry or Pharmacol intervention.

• Discuss the need to maintain regular sleep and wake schedule and sleep hygiene techniques including limiting caffeine after 2 pm, limiting fluids after dinner, limiting screen time or stimulating activities after 8 pm, and getting out of bed if awaken in the middle of 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.

Comments

Professional Development

Write a 1000-word APA reflection essay on 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?