SHADOW HEALTH NICOLE DIAZ- PTSD

Established chief complaint Reports sleep problems 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 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. Reports that stress and anxiety exacerbate sleep problems. Asked about existing health conditions Reports hypertension diagnosis Followed up on hypertension diagnosis Diagnosed at 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 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. Reports stress triggers PTSD symptoms. Reports avoiding crowds or most social situations. All the best from Dr. A Dr. Assessments Page 2 of 7 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 like 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. Asked about past suicide attempts Denies past suicide attempts. Asked about homicidal ideation Denies homicidal ideation. Asked about previous psychiatric hospitalizations. Denies past psychiatric admissions. Asked about home medications Reports medication for hypertension. Reports medication for depression. Reports medication for anxiety. Denies taking vitamins. Denies taking herbal supplements. Asked about medication regimen adherence 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. 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. Reports taking losartan Reports taking losartan dosage: 100 mg. Reports losartan frequency: 1xdaily.