Nicole Diaz PTSD shadow health Subjective Data Collection

• 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?

• 
  

  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

  (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:

  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”

  (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:

  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

  (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 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

  (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 wake up?
• 
  

  Finding:

  Reports sleeping an average of 4 or 5 hours a night

  (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 much sleep do you get a night?
• 
  

  Finding:

  Reports sleeping alone in a quiet room

  (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:

  Can you describe where you sleep?

• 
  

  Finding:

  Asked about patterns for sleep problems

• 
  

  Finding:

  Reports that stress and anxiety exacerbate sleep problems

  (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.Nicole Diaz PTSD shadow health Subjective Data Collection

  Example Question:

  What makes it harder for you to sleep?

• 
  

  Finding:

  Asked about existing health conditions

• 
  

  Finding:

  Reports hypertension diagnosis

  (Found)

  Nicole Diaz PTSD shadow health Subjective Data Collection Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Do you have high blood pressure? Nicole Diaz PTSD shadow health Subjective Data Collection

• 
  

  Finding:

  Followed up on hypertension diagnosis

• 
  

  Finding:

  Diagnosed age 45

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  When was your high blood pressure first diagnosed?

• 
  

  Finding:

  Asked about history of mental health

• 
  

  Finding:

  Reports PTSD diagnosis

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Do you have PTSD?

• 
  

  Finding:

  Followed up about symptoms of PTSD diagnosis

• 
  

  Finding:

  Reports depression accompanies PTSD diagnosis

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  What makes you feel depressed?
• 
  

  Finding:

  Reports anxiety as a symptom of PTSD

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  What makes you anxious?
• 
  

  Finding:

  Reports sleep problems are a symptom of PTSD diagnosis

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment Nicole Diaz PTSD shadow health Subjective Data Collection.

  Example Question:

  What are the symptoms of your PTSD?

• 
  

  Finding:

  Followed up on onset of PTSD

• 
  

  Finding:

  Reports diagnosis age 35

  (Available)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  When were you diagnosed with PTSD?
• 
  

  Finding:

  Reports PTSD cause is military sexual assault

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  What brought on the post traumatic stress disorder?
• 
  

  Finding:

  Reports MST was at age 23

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  How long have you had MST?
• 
  

  Finding:

  Reports event involved commanding officer and ostracization from unit

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  What happened when you were sexually assaulted?
• 
  

  Finding:

  Reports left military at 28, but did not seek immediate care

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  When did you get help for your PTSD symptoms?

• 
  

  Finding:

  Followed up on aggravating factors for PTSD

• 
  

  Finding:

  Reports stress triggers PTSD symptoms

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  How do you experience stress?

• 
  

  Finding:

  Reports avoiding crowds or most social situations

  (Available)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Does your anxiety prevent you from completing your usual activities?
• 
  

  Finding:

  Reports fear of “losing control” of a situation

  (Available)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Do you feel nervous in new situations?
• 
  

  Finding:

  Reports discussing event is triggering

  (Available)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Are you ok with talking about what happened?
• 
  

  Finding:

  Reports difficulties with relationships and emotional/physical intimacy

  (Available)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  How does ptsd affect your relationships?

• 
  

  Finding:

  Asked about non-medication coping strategies

• 
  

  Finding:

  Reveals belief that she has a moderate level of self-care

  (Available)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  How do you perceive your health?
• 
  

  Finding:

  Reports therapy dog helps

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  How does your service dog help?
• 
  

  Finding:

  Reports smoking helps

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  How do you cope with anxiety?
• 
  

  Finding:

  Reports avoiding stimulating environments when anxious or stressed

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  How do you cope with anxiety?

• 
  

  Finding:

  Asked about suicidal ideation and self-harm

• 
  

  Finding:

  Reports occasional feelings that “sometimes I feel like life is not worth living”

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Have you ever thought about hurting yourself?
• 
  

  Finding:

  Denies active suicidal ideation or self-harm

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.Nicole Diaz PTSD shadow health Subjective Data Collection

  Example Question:

  Have you ever tried to hurt yourself?

• 
  

  Finding:

  Followed up on suicide planning

• 
  

  Finding:

  Denies suicide planning

  (Found)

  Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.

  Example Question:

  Have you ever tried to hurt yourself?
• 
  

  Finding:

  Reports suicidal ideation is a symptom of depression Nicole Diaz PTSD shadow health Subjective Data Collection

Nicole Diaz’s PTSD Shadow Health Subjective Data Collection

Subjective Data Collection: 39 of 39 (100.0%)

Category: Scored Items

Experts have selected these topics as essential components of a comprehensive interview with this patient.

**Chief Complaint:**
– Established chief complaint
– Reports sleep problems

**History of Present Illness:**
– Asked about onset and frequency of sleep problems
– Reports sleep problems for the past 10+ years
– Reports having problems sleeping most nights of the week
– Asked about sleep quality and characteristics
– 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
– Reports going to bed “around midnight,” but feeling “too nervous” to sleep
– Reports actually falling asleep at 2 or 3 AM
– Reports checking windows and doors twice before going to bed
– Reports no screen use (television or computer) before bed
– Reports average wake time of 7 AM
– Reports sleeping an average of 4 or 5 hours a night
– Reports sleeping alone in a quiet room
– Asked about patterns for sleep problems
– Reports that stress and anxiety exacerbate sleep problems

**Past Medical History:**
– Asked about existing health conditions
– Reports hypertension diagnosis
– Followed up on hypertension diagnosis
– Diagnosed age 45
– Asked about history of mental health
– Reports PTSD diagnosis
– Followed up about symptoms of PTSD diagnosis
– 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
– Reports diagnosis age 35
– Reports PTSD cause is military sexual assault
– Reports MST was at age 23
– Reports event 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
– 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
– 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
– Reports occasional feelings that “sometimes I feel like life is not worth living”
– Denies active suicidal ideation or self-harm
– Followed up on suicide planning
– Denies suicide planning
– Reports suicidal ideation is a symptom of depression

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