Abigail Harris Depression shadow health transcript
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Hell. I am xxxx, I will interview you and later conduct a physical exam
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Greet |
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Hey.
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What brings you here today?
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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.
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Am sorry about that
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Empathize |
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I’m grateful for that.
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How long have you had your symptoms?
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I’ve lived with my diabetes for 36 years.
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How long have you been feeling exhausted and weak? (Clarified to How long have you been feeling fatigued?.)
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I’ve been tired for quite a while, but I’ve always been able to go about my day alright until about a month ago. It’s been getting worse this last week too… some mornings I just stay in bed. I guess I’m just slowing down more and more, should be expected at my age I suppose Abigail Harris Depression shadow health transcript . (Clarified to how long I have been fatigued.)
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Do you feel fatigued everyday? (Clarified to When are you most tired?.)
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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. (Clarified to when I am most tired.)
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What worsens your symptoms?
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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.
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Have you lost interest in daily activities? (Clarified to Do you take interest in activities?.)
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My interests haven’t really changed, I just haven’t really felt like doing any of them. (Clarified to if I take interest in activities.)
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Do you take pleasure in things that you typically would? (Clarified to Do you not find pleasure in things you used to like?.)
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Yes, I no longer feel like really enjoy too much anymore. Going to church, seeing my friends, even family dinner hasn’t seemed as nice as it used to. I’m not sure why, it’s just how I feel. (Clarified to if I do not find pleasure in things I used to like.)
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What relieves your symptoms?
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All I want to do when I feel tired is just lie down. It’s what feels best when I get like that.
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Do you feel depressed?
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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.
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Any sleep problems?
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I’ll generally have a little trouble falling asleep and staying like that. I think my doctor called it mild insomnia.
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How often do you experience low energy?
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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.
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How is your appetite?
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My appetite has been quite small lately, I’ll usually just have something small more days than not.
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Do you feel guilty?
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Well I feel guilty for not really making it out to church… or anywhere for that matter. It’s quite embarrassing to think what it must seem like to all of them.
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Do you feel bad about yourself?
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Frankly, I feel guilty. Guilty and embarrassed, hiding away from the world like I do, stuck in bed.
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Any changes in your concentration?
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Yes, I’ve been having quite a hard time concentrating actually.
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Any changes in speed with moving or eating?
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Not that I’ve noticed, no.
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Any suicidal ideation?
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No, no. It’s not like that. I’ve never wanted to hurt myself before, it’s just. . . if this is it, then I don’t want to have to live with it year in and year out. It’s exhausting.
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Am sorry about that
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Empathize |
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Its nice to hear you get it.
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Any other health problems?
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I don’t really have anything else. Just the diabetes, depression, and my thyroid.
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Any allergies?
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I’ve never had any trouble with allergies, no.
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Any medication allergies?
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I don’t have medication allergies.
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I have a little farsightedness, but Doctor Williams told me that was normal for someone my age. I have some glasses I use for reading to take care of it anyway.
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Any hearing problems?
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My hearing definitely isn’t as good as it used to be, but my doctor says that’s normal.
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Any cough?
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I haven’t been coughing more than normal, no.
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Any shortness of breath?
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No, I don’t feel like I have any breathing problems right now. But if I walk for too long or go too fast, I’ll get a little short of breath.
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Any chest pain?
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No, I haven’t had any chest pain.
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Any palpitations?
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I don’t have to worry about palpitations. I never have had them.
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I’ve been constipated occasionally for the past month. I’ve only been able to go once every two or three days, and even then I have to strain.
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Any joint pain?
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It doesn’t seem all that serious to me but my joints have been a bit achy. I’m not taking any medication for them, but I do try to rest them when I can.
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Any recent injury?
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No, no recent injuries. I’ve been taking it as easy as I can for the most part these days.
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How would you describe your joint pain?
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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.
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Any dizziness?
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I wouldn’t say I’m particularly dizzy right at this moment, but I have been lately. I usually feel it in the mornings when I get up. Abigail Harris Depression shadow health transcript
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How do you manage your diabetes?
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I have an insulin regimen that my son helps me with. I usually take some of it with meals, but I haven’t been very hungry so I just take it around those times.
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To better manage your diabetes, you need a proper diet, medication, and exercise
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Educate |
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Oh, okay. Thank you.
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Do you think your age has contributed to your symptoms? (No matching questions found.)
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Are your symptoms associated with your age? (No matching questions found.)
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Assessed vitals
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Assessed IV bag
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Assessed IV pump Abigail Harris Depression shadow health transcript
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Assessed IV site
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Assessed blood glucose: preprandial and hypoglycemic
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Assessed urine quality
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Do you feel safe in your house?
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I feel quite safe at home. My son and his family treat me well, and I love being so close with my grandkids.
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Inspected eyes
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Inspected mouth
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Inspected front of neck
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Inspected abdomen
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Inspected front of right hand
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Inspected front of left hand Abigail Harris Depression shadow health transcript
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Inspected front of legs
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Inspected feet: Skin intact on dorsal and plantar surfaces bilaterally, no evidence of breakdown
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Inspected left shoulder and neck
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Inspected top of left hand
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Inspected left leg
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Inspected left foot: Skin of left foot intact, no evidence of breakdown
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Inspected upper back and neck
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Inspected lower back
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Inspected left palm
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Inspected right palm
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Inspected back of legs
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Inspected back of feet: Skin intact on heels bilaterally, no evidence of breakdown
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Inspected right shoulder and neck
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Inspected top of right hand
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Inspected right leg
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Inspected right foot: Skin of right foot intact, no evidence of breakdown
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Inspected back of feet: Skin intact on heels bilaterally, no evidence of breakdown
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Auscultated carotids
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Auscultate breath sounds
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Auscultate heart sounds
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Palpated thyroid: No palpable abnormalities and no tenderness reported
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Tested fine motor skills
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Tested grip strength
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Tested skin turgor
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Tested capillary refill
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Tested gait: no hesitancy, steps are continuous, no sway, heels set apart, and less than 12 seconds to complete
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Assessed general appearance: No eye contact, upright posture, clean clothing, and demonstrates appropriate level of grooming.
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Assessed attitude toward medical staff: open and cooperative
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Assessed speech: expected rate of speech, soft speech volume, and no appreciable issues with articulation
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Assessed mood and affect: stable mood, but affect is blunted or flat
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Assessed thought process: no presence of thought disturbances
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Assessed thought content Abigail Harris Depression shadow health transcript
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Confirmed orientation
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What is your name and date of birth?
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Abigail Harris and my date of birth is . . . [Ms. Harris reports her correct date of birth.] Abigail Harris Depression shadow health transcript
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What building are you in now?
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We’re in the hospital — Shadow General.
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What is the date and year?
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Yes, it’s . . . [Ms. Harris reports the correct date and year.]
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Assessed cognition
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Count backwards from 100 by 7 until you get to the 60s.
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Goodness. Well … 100, 93, 86, 79… [Ms. Harris finishes the sequence]
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Assessed cognition
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How are apples and oranges alike?
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Those are both fruits.
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How are a lake and ocean alike?
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Those are both bodies of water.
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How are a trumpet and a flute alike?
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Those are both instruments.
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Assessed cognition
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Repeat and remember burger, tulip, nose, and tea
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Burger, tulip, nose and tea. OK.
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How did you celebrate your last birthday? Abigail Harris Depression shadow health transcript
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I celebrated with my son’s family — my daughter-in-law prepared a nice meal and baked a lovely cake with my grandchildren.
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Repeat the four words from before.
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Burger, tulip, nose, and tea.
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Copy the shapes exactly as you see them.
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OK, I’ll try.
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Assessed insight: demonstrates awareness of illness and willingness to seek treatment
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Assessed judgment: demonstrates good judgment
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What would you do if you found a stamped envelope on the sidewalk?
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Well, if anyone was around, I suppose I would ask if they dropped the envelope. If not, I would try to find a post box.
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