Shadow Health Nicole Diaz-
PTSD
Established chief complaint ans: Reports sleep problems
Asked about onset and frequency of sleep problems ans: Reports sleep problems for the past 10+ years
Reports having problems sleeping most nights of the week
Asked about sleep quality and characteristics ans: Reports recent sleep problems 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.
Asked about sleep habits ans: 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.
Asked about patterns for sleep problems. ans: Reports that stress and anxiety exacerbate sleep
problems.
Asked about existing health conditions ans: Reports hypertension diagnosis
Followed up on hypertension diagnosis ans: Diagnosed at age 45
Asked about history of mental health ans: Reports PTSD diagnosis
Followed up about symptoms of PTSD diagnosis ans: Reports depression accompanies PTSD diagnosis.
Reports anxiety as a symptom of PTSD.
Reports sleep problems are a symptom of PTSD diagnosis.
Followed up on onset of PTSD ans: 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.
Followed up on aggravating factors for PTSD. ans: Reports stress triggers PTSD symptoms.
Reports avoiding crowds or most social situations.
Reports fear of "losing control" of a situation.
, Reports discussing event is triggering.
Reports difficulties with relationships and emotional/physical intimacy.
Asked about non-medication coping strategies ans: Reveals belief that she has a moderate level of self-
care.
Reports therapy dog helps.
Reports smoking helps.
Reports avoiding stimulating environments when anxious or stressed.
Asked about suicidal ideation and self-harm. ans: Reports occasional feelings that "sometimes I feel like
like is not worth living"
Denies active suicidal ideation or self-harm.
Followed up on suicide planning. ans: Denies suicide planning.
Reports suicidal ideation is a symptom of depression.
Asked about past suicide attempts ans: Denies past suicide attempts.
Asked about homicidal ideation ans: Denies homicidal ideation.
Asked about previous psychiatric hospitalizations. ans: Denies past psychiatric admissions.
Asked about home medications ans: Reports medication for hypertension.
Reports medication for depression.
Reports medication for anxiety.
Denies taking vitamins.
Denies taking herbal supplements.
Asked about medication regimen adherence ans: Reports using a smartphone app to manage
medication.
Denies missing doses of medications.
Denies difficulty obtaining medications because of finances.
Denies difficulty obtaining medications because of transportation.
Followed up on last dose of home medications. ans: Reports taking all medications as scheduled today.
Denies taking blood pressure medication today- not scheduled until evening.
Reports taking medication for depression this morning as scheduled.
Reports taking medication for anxiety this morning as scheduled.
Followd up on medication for hypertension. ans: Reports taking losartan
Reports taking losartan dosage: 100 mg.
Reports losartan frequency: 1xdaily.
Denies losartan side effects
Followed up on medication for anxiety. ans: Reports taking buspirone HCL.
Reports buspirone HCL dosage: 30 mg.
Reports buspirone HCL frequency: 15 mg pill twice daily.
Denies buspirone HCL side effects.
PTSD
Established chief complaint ans: Reports sleep problems
Asked about onset and frequency of sleep problems ans: Reports sleep problems for the past 10+ years
Reports having problems sleeping most nights of the week
Asked about sleep quality and characteristics ans: Reports recent sleep problems 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.
Asked about sleep habits ans: 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.
Asked about patterns for sleep problems. ans: Reports that stress and anxiety exacerbate sleep
problems.
Asked about existing health conditions ans: Reports hypertension diagnosis
Followed up on hypertension diagnosis ans: Diagnosed at age 45
Asked about history of mental health ans: Reports PTSD diagnosis
Followed up about symptoms of PTSD diagnosis ans: Reports depression accompanies PTSD diagnosis.
Reports anxiety as a symptom of PTSD.
Reports sleep problems are a symptom of PTSD diagnosis.
Followed up on onset of PTSD ans: 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.
Followed up on aggravating factors for PTSD. ans: Reports stress triggers PTSD symptoms.
Reports avoiding crowds or most social situations.
Reports fear of "losing control" of a situation.
, Reports discussing event is triggering.
Reports difficulties with relationships and emotional/physical intimacy.
Asked about non-medication coping strategies ans: Reveals belief that she has a moderate level of self-
care.
Reports therapy dog helps.
Reports smoking helps.
Reports avoiding stimulating environments when anxious or stressed.
Asked about suicidal ideation and self-harm. ans: Reports occasional feelings that "sometimes I feel like
like is not worth living"
Denies active suicidal ideation or self-harm.
Followed up on suicide planning. ans: Denies suicide planning.
Reports suicidal ideation is a symptom of depression.
Asked about past suicide attempts ans: Denies past suicide attempts.
Asked about homicidal ideation ans: Denies homicidal ideation.
Asked about previous psychiatric hospitalizations. ans: Denies past psychiatric admissions.
Asked about home medications ans: Reports medication for hypertension.
Reports medication for depression.
Reports medication for anxiety.
Denies taking vitamins.
Denies taking herbal supplements.
Asked about medication regimen adherence ans: Reports using a smartphone app to manage
medication.
Denies missing doses of medications.
Denies difficulty obtaining medications because of finances.
Denies difficulty obtaining medications because of transportation.
Followed up on last dose of home medications. ans: Reports taking all medications as scheduled today.
Denies taking blood pressure medication today- not scheduled until evening.
Reports taking medication for depression this morning as scheduled.
Reports taking medication for anxiety this morning as scheduled.
Followd up on medication for hypertension. ans: Reports taking losartan
Reports taking losartan dosage: 100 mg.
Reports losartan frequency: 1xdaily.
Denies losartan side effects
Followed up on medication for anxiety. ans: Reports taking buspirone HCL.
Reports buspirone HCL dosage: 30 mg.
Reports buspirone HCL frequency: 15 mg pill twice daily.
Denies buspirone HCL side effects.
