Exam (elaborations)
Shadow Health -Nicole Diaz- PTSD|PSYCHC487 |Western Governors University
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Shadow Health -Nicole Diaz- PTSD|PSYCHC487 |Western Governors University
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“ Nicole Diaz- PTSDChief Complaint
Finding:
Established chief complaint
Finding:
Reports sleep problems
(Found)
Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting.
Asking about the chief complaint will allow the patient to voice any concerns or symptoms
the patient may have.
Example Question:
What are your symptoms?
History of Present Illness
Finding:
Asked about onset and frequency of sleep problems
Finding:
Reports sleep problems for the past 10+ years
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Do you have a history of sleep problems?
Finding:
Reports having problems sleeping most nights of the week
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
How long have you been having sleep problems?
Finding:
,Asked about sleep quality and characteristics
Finding:
Reports recent sleep problems include nightmares
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
What wakes you up at night?
Finding:
Reports falling asleep often takes more than an hour
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
How long does it take for you to fall asleep?
Finding:
Reports waking up two or three times during the night for "at least ten minutes"
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
How often do you wake up during the night?
Finding:
Reports waking in the morning feeling "out of it" and not rested
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
How do you feel when you wake up in the morning?
Finding:
Reports frequent snoring
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Do you snore?
Finding:
Asked about sleep habits
, Finding:
Reports going to bed "around midnight," but feeling "too nervous" to sleep
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
What is your sleep like?
Finding:
Reports actually falling asleep at 2 or 3 AM
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
What time do you fall asleep?
Finding:
Reports checking her windows and doors twice before going to bed
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
What do you usually do before bed?
Finding:
Reports no screen use (television or computer) before bed
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
Do you use the computer or watch TV before you go to sleep?
Finding:
Reports average wake time of 7 AM
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
follow-up on any present conditions or symptoms, such as the location of their pain or the
amount of pain they may be experiencing.
Example Question:
What time do you wake up?
Finding:
Reports sleeping an average of 4 or 5 hours a night
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information
relevant to the history of their present illness. Details of their current complaint will help you
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