Tina Jones Mental Health Shadow Health Assessment Transcript
Transcript
Started: Jun 14, 2020 | Total Time:71 min
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Hi Ms. Jones, my name is Danielle. I will be you Health care provider today
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Greet |
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Hey.
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What brings you in today?
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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.
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I’m sorry to hear about your trouble sleeping and stress. I’m glad you came in today. let me learn more about what you’re experiencing, and i will try to help
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Empathize |
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I appreciate you saying that.
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when did you start have trouble sleeping?
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This all started almost a month ago. . . it’s been happening regularly for about three and a half weeks, I’d say.
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How often do you have difficulty sleeping?
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It’s happening most nights, I’d say. Four. . . more like five nights a week.
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What are factors that prevent you from sleeping? (No matching questions found.)
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What prevents you from sleeping? (Clarified to What were you thinking about when you couldn’t sleep?.)
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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. (Clarified to what I was thinking about when I could not sleep.)
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Do you drink coffee
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Never. I don’t like it. Too bitter for my taste.
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Do you take naps during the day?
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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.
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Is there anything preventing you from falling asleep (Clarified to Is there anything that helps you fall asleep?.)
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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. (Clarified to if I anything helps me sleep.)
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Do you exercise
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I just don’t have time to exercise, honestly.
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Do you drift off during the day?
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No, though I do feel groggy during the day.
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Are you tired during the day?
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I’m pretty much tired all the time. I just really need more sleep.
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do you have anxiety?
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I’ve never been diagnosed with anxiety or anything. . . I think usually I’m a pretty relaxed person. At least until recently.
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Do you have a history of panic attacks
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I’ve never had a panic attack, no.
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How does anxiety affect daily life (Clarified to How does your anxiety interfere with your daily life?.)
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Being anxious is mostly just interfering with my sleep, and then not being able to get enough sleep is interfering with my life. (Clarified to how my anxiety interferes with my daily life.)
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how is you quality of sleep (Clarified to Do you sleep ok?.)
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Lately I haven’t been getting enough sleep at all. It takes me so long to fall asleep at night–it’s really frustrating. (Clarified to if I sleep well.)
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what are you sleep habits?
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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.
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how are you coping with stress
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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.
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What is causing the stress
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I’m stressed now because I can’t sleep, but I can’t sleep because I keep worrying about all this other stuff, like graduating, and passing this exam that’s coming up, and getting a job, and finding my own place to live. . . it’s a lot.
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It sounds like you have a lot on your plate. I am sorry you are dealing with so much stress
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Empathize |
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I appreciate you telling me that.
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What were you thinking about when you couldn’t sleep?
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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.
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what are your sleep patterns (Clarified to What are your sleep habits?.)
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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. (Clarified to what my sleep habits are.)
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It”s hard to function at our best when we don’t get enough sleep. I know you are busy with work and school, but let’s talk about some strategies to help you get more sleep and make sure you’re getting good quality sleep.
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Empathize |
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Thanks.
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Tell me more about “feeling put of it”
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I don’t know what you want to know. . . mostly, it’s that I can’t get to sleep at a reasonable time, but I also feel like the quality of my sleep is worse in general.
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what do you mean by “feeling out of it”
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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.
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Tell me about your medical history
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I’ve had asthma since I was little, and I have sugar diabetes, too.
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Do you take any medications?
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All I have is a Proventil inhaler and a Flovent inhaler for my asthma.
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Do you take any medications for sleep
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I haven’t tried taking anything to sleep–I would really rather avoid having to take medication if possible.
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Do you have any new allergies
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Nope.
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Do you have a history of sleeping problems?
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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.
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DO you have a history of depression
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I was pretty sad after Dad died, but I wouldn’t say it was, like, true depression. I definitely wasn’t diagnosed with it or anything.
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Do you have difficulty making decisions?
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Only in the sense that, like, everything I do is a little harder because I’m out of it from not sleeping.
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Do you feel hopeless
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I don’t feel hopeless, just frustrated and stressed out.
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Do you have thoughts of wanting to hurt yourself
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No, I’ve never wanted to hurt myself.
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Do you have suicidal thought?
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No, never.
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Do you have any past traumas
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No, not really.
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Do you have a history of violence
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No, never.
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Are you employed
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I’m a supervisor at Mid-American Copy & Ship. I’ve been working there since high school, and I’ve just kept moving up.
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Are you in school
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Yeah, I’m about to get my B.A. in Accounting.
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Do you have an hobbies
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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.
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Have you been in the military
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No, I’ve never been in the military.
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Do you have a legal history
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No way.
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What is you current living situation
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I’m living back at my mom’s house with her and my sister. It’s the house I grew up in–we each have our own bedroom, and there’s also a kitchen and a living room. It’s all one story. It can be kind of weird, being my age and living with my family again, but I’ve enjoyed spending time with my family, and I’m happy to help out. I’m looking forward to getting my own place soon, though.
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Do you get along with your family
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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.
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Do you have religious preference?
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Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too.
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does your family support you
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Yeah, definitely. We’re all pretty tight knit. I think we’re a pretty special family, the way we all get along. My brother moved in with his fiance, but we still see him once a week at least, and I eat dinner with my mom and sister as much as possible, plus they always go to church with me on Sundays.
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It sounds like you have a healthy support system through your family and friends which is great. it sounds like you work hard to manage your time effectively, too. remember to take out to relax or take a walk
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Empathize |
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Thanks for understanding.
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Do you use illicit drugs?
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No.
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Have you used marijuana
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Well, I used to smoke pot. . . but I don’t do that anymore.
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when was the last time you smoked marijuana
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I haven’t smoked pot since I was twenty or twenty-one.
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Do you drink alcohol
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I do sometimes, yeah, when I go out with my friends.
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how often do you drink
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No more than once or twice a week. . . a lot of time less than that.
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how much do you drink
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Not often–a couple times a month I’ll go out for a few drinks with friends.
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how many drink do you drink per month (Clarified to How many times a month do you drink?.)
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Not much. I go out for drinks with friends maybe a couple times a month. (Clarified to how many times a month I drink alcohol.)
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how many drink do you drink in a month (Clarified to How many drinks do you have per month?.)
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Oh, I don’t know. Let’s see. . . I might go out every few weeks, so twice a month. . . and I maybe have 2 or 3 drinks at a time, so that’s like 6 drinks a month. I guess if I’m free to go out more than that, it might be up to 12 drinks in a month, but that’s pretty rare. (Clarified to how many alcoholic drinks I have a month.)
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do you drink and drive
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We usually take a cab when we go out.
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so you use tobacco products
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No, never.
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do you vape
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I don’t vape. Ew. [AUDIO COMING SOON]
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Do you abuse prescription drugs?
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No! I don’t know why I’d want to take someone else’s prescriptions. . . I hate having to take my own medicines.
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What is your relationship status
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I’m single right now.
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how long have you been single?
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I broke up with my last boyfriend about three years ago.
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Are you sexually active
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No, I haven’t been in a while.
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have anyone hurt you
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No, never.
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do you have any family members with a history of mental illness
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No. They’re crazy, but nobody’s diagnosed with anything.
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