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PSYCH C487 Shadow Health Nicole Diaz- PTSD with complete solution
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PSYCH C487 Shadow Health Nicole Diaz- PTSD with complete solution
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Shadow Health Nicole Diaz- PTSD1. Established chief complaint: Answer- Reports sleep problems
2. Asked about onset and frequency of sleep problems: Answer- Reports
sleep prob- lems for the past 10+ years
Reports having problems sleeping most nights of the week
3. Asked about sleep quality and characteristics: Answer- Reports recent
sleep prob- lems include nightmares.
Reports falling asleep often takes more than an hour.
Reports waking up two or three times during the night for "at least ten
minutes" Reports waking in the morning feeling "out of it" and not
rested.
Reports frequent snoring.
4. Asked about sleep habits: Answer- Reports going to be "around
midnight", but feeling "too nervous" to sleep.
Reports actually falling asleep around 2 or 3am
Reports checking her windows and doors twice before going
to bed. Reports no screen use (tv or computer) before bed.
Reports average wake up time of 7am.
Reports sleeping an average of 4 or 5 hours a
night. Reports sleeping alone in a quiet room.
5. Asked about patterns for sleep problems.: Answer- Reports that
1/
, stress and anxiety exacerbate sleep problems.
6. Asked about existing health conditions: Reports hypertension diagnosis
7. Followed up on hypertension diagnosis: Diagnosed at age 45
8. Asked about history of mental health: Reports PTSD diagnosis
9. Followed up about symptoms of PTSD diagnosis: Reports depression
ac- companies PTSD diagnosis.
Reports anxiety as a symptom of PTSD.
Reports sleep problems are a symptom of PTSD diagnosis.
10.Followed up on onset of PTSD: Reports diagnosed at age
35. Reports PTSD cause is military sexual assault.
Reports MST was at age 23.
Reports even involved commanding officer and ostracization
from unit. Reports left military at 28, but did not seek
immediate care.
11.Followed up on aggravating factors for PTSD.: Reports stress
triggers PTSD symptoms.
Reports avoiding crowds or most social
situations. Reports fear of "losing control"
of a situation.
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