PSYCH C487 > Focused Exam PTSD Completed Shadow Health documentation

Nursing Admitting Note Student Documentation Model Documentation Chief Complaint not being able to sleep, trouble following asleep Ms. Diaz presented at the clinic with severe sleep issues that she said were impacting her life. She claimed she was unable to rest and was suffering from insomnia, nightmares, and frequent waking. History of Present Illness cant sleep until 2 or 3 in the morning, too nervous to sleep, only getting four or five hours of sleep per night, history of PTSD Nicole is a 48 year-old Cuban American woman with a history of hypertension and post-traumatic stress disorder. Allergies nkda NKA Past Medical History htn, ptsd HTN diagnosed age 45 PTSD diagnosed age 35 stemming from a sexual assault during her military service