Reason for Encounter: Fatigue
Good Questions
- How can I help you today? My mom made me come here because I’m tired all the time (eyes are tearful, slightly annoyed tone of voice).
- Do you have any other symptoms or concerns we should discuss? I don’t think I have any symptoms….I’m just here because of my mother.
- When did your fatigue/tiredness start? I don’t know, maybe about two months or so ago?
- What are the events surrounding the start of your fatigue/tiredness? I don’t know (eyes are tearful). Maybe I just feel a lot of pressure because it’s my senior year. They lay on a lot of pressure, you know?
- Does your fatigue/tiredness improve after a good night’s rest? I think I get enough sleep, but I still wake up tired. It doesn’t seem to matter. I’m always tired.
- Have you been feeling sad, depressed, or hopeless? If so, how often do you feel this way? No….well, I feel like I can’t do anything right - school isn’t fun anymore, just doesn’t seem worth it most of the time. I get so upset and frustrated, I’m crying every day! I do find my parents irritating and they are always on my case (eyes are tearful).
- Have you been nervous, anxious, or worried about something? Yeah. Especially about college….I know that if I don’t get into college with a scholarship, then my parents will think that I’m worthless (starts crying). And there’s no way I’ll get in with how things are going so far this year.
- Are you crying more than usual? Yeah…..I cried daily after I lost my boyfriend, but that was months ago and I’m over it! I don’t really understand why I started crying daily again, just this last month….but I’m really not thinking about him….I just find everybody annoying and so I start crying.
- How are your grades in school? I just can’t focus on school as well as I used to. Last semester I had a 3.5 GPA. We’ve only had a few tests so far this fall and I got C’s on two of them. I just don’t care about my grades as much as I used to.
- Are you having any difficulty sleeping? No!! Thank goodness, that’s the only time no one bothers me at home.
- Do you blame yourself for everything wrong? Yes about my boyfriend, I’m not sure why he left me so that is probably my fault. But when it comes to my family, they are just on my case and I don’t understand it……I guess I have no one to blame but myself for my weight if that’s what you mean…..
- Have you had any thoughts of hurting or killing yourself? No, I would never do anything stupid like that. But sometimes I wish I could just disappear and not have to deal with anything anymore.
- Do you wish you were not alive anymore or fell asleep and didn’t wake up? If so, how often have you had these thoughts? On some school days, I wish I could just disappear and hide from the world…..
- Have you gained or lost weight unintentionally, despite normal appetite and exercise? I’ve put on some weight, maybe 25-30 pounds or so since last year. I wasn’t trying to….I think it’s maybe just because I’m maturing as a woman…..or maybe because I stopped track, I don’t know. But now I’ve got these ugly stretch marks! Do you know what causes these?!?! I hate them!
- Tell me about daily exercise or sports that you play. None really now. I used to be on the track team, but I didn’t try out. I just don’t have the energy…. (eyes are tearful).
- How would you describe your moods? Well, my family says I’m “crabby” and they want to blame it on my periods. But I feel the same way all month long…..they just annoy me a lot, okay?
- Do you find that it is hard to experience feelings like happiness, love, or satisfaction? I guess I might still be down from the breakup….
- Have you lost interest in or avoided social activities? I don’t avoid social activities….well, maybe I do a little bit since my boyfriend had dumped me for one of my friends — we went to prom together. I haven’t dated anyone since then, and I don’t want to.
- How is your appetite? Any recent change? Sort of. I feel hungry all the time….
- Can you tell me about your diet? What do you normally eat? I skip breakfast because I have been gaining weight….the rest of my diet is about the same, I have pizza and maybe french fries for lunch two or three times a week and french fries as a snack on the way home. My mom cooks dinner, but by the time I am doing my homework at night, I am so tired that I need snacks to keep me going.
- How is your family and family life? I have to share a room with my sister, who is a freshman. I can’t stand the way she is so excited about high school and the messes she makes in our room drive me inside! My sister and her friends are so annoying, too!! (crying) My mother’s constantly on me about spending too much time on the internet, rather than being “social” as she calls it. And she’s also on me about helping around the house. So, is that what you want to know?
- Are there any guns in your home? If so, are they stored in a secure location? No guns.
- Are you sexually active? I had sex a few times last year with my boyfriend. That’s over and I haven’t done it since.
- Is it possible that you are pregnant? That’s what they all ask! I am not pregnant I’ve never been pregnant’ my periods are like clockwork; my last one was two weeks ago; and I certainly don’t have those symptoms they drill into your head in health. Besides I don’t have a boyfriend, okay?
- Any new or recent change in medications? No, no prescription meds. Is that what you mean?
- Are you taking any OTC or herbal medications? I take ibuprofen for menstrual cramps; they’re there with each period, but not that bad.
- Do you drink alcohol? If so, what do you drink, and how many drinks per day? I only really drink beers at parties….well, maybe occasionally just with my friends. But it’s not a problem.
- Has drinking alcohol ever caused you any problems? No, but it probably did if my mom knew I drank as much as I do.
- Has anyone suggested that you should reduce the amount of alcohol you drink? No.
- Do you feel guilty about the amount of alcohol you drink? Not at all.
- Do you use any recreational drugs? If so, what? I tried marijuana once last year with my old boyfriend. Nothing else though.
- Are your immunizations up to date? Yeah, they kind of have to be if I want to go to school.
- Do you have any allergies? None that I know of.
- Skin/hair/nails: Do you have any problems with itchy scalp, skin changes, moles, thinning hair, brittle nails? What do you mean by skin changes?
- HEENT: Do you have any problems with headaches that do not go away with aspirin or Tylenol… No. Denies headaches. Denies double or blurred vision or difficulty seeing at night, and denies problems hearing or ear pain. Denies sinus problems, chronic sore throats, or difficulty swallowing.
- Breast: Have you noticed any discharge from your breast, lumps, scaly nipples, pain or swelling, redness? No. Denies breast discharge, lumps, scaly nipples, pain, swelling, or redness.
- Cardiac: Do you experience chest pain, discomfort, pressure, pain/pressure/dizziness with exertion or getting angry? No. Denies chest pain, discomfort, or pressure; denies any pain/pressure/dizziness with exertion or getting angry; denies palpitations, denies exercise intolerance, denies blue/cold fingers or toes.
- Respiratory: Do you experience shortness of breath, wheezing, difficulty catching your breath, chronic cough, sputum production? No. Denies shortness of breath, wheezing, difficulty catching your breath, chronic cough, or sputum production.
- GI: Do you have problems with nausea, vomiting, constipation, diarrhea, coffee grounds… No. Denies any nausea, vomiting, constipation, diarrhea, coffee grounds in vomit, dark tarry stool, bright red blood in bowel movements, denies any satiety or bloating.
- Hemat: Have you noticed any bruising or bleeding gums or other sites… No.
- Neuro: Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness… No.
- GU: When you urinate, have you noticed: pain, difficulty starting or stopping… No. Denies difficulty urinating, denies any pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night, denies any change in frequency.
- Endocrine: Uh….I don’t think so. Denies any heat or cold intolerance, increased thirst or sweating, denies frequent urination, or change in appetite.
