Anca Popa
GNRS 534
PTSD (F43.1)
Criteria Clinical Notes
Subjective CC: Family stated …you’ve been afraid to leave the house.” Or “ I
Include chief can’t go out”
complaint, subjective HPI: K.A. is a 22-year-old Hispanic female who presented to the
information from the clinic for evaluation because her family has been stating that she is
patient, names and afraid to leave the house. She reported that she feels uncomfortable
relations of others and threatened by unfamiliar places and people, and that she only
present in the feels safe at home when her family is around. She is afraid of being
interview, and basic alone after the sexual assault, 7 months ago. She reports
demographic nightmares, and re-experiencing the traumatic event over and over
information of the and waking up screaming. K.A. states her boyfriend, Josh, helps her
patient. HPI, Past relax when she wakes up crying from these nightmares by holding
Medical and her and assisting her back to sleep. She states she is a terrible
Psychiatric History, person because of her inability to get out of the house without the
Social History. help of her family (dad, mom, or sister), or her boyfriend, and when
at home she is irritable, cries a lot, and she cannot function normally.
K.A. reports that their relationship and sexual life are affected by her
sense of guilt, and her feelings of being tainted. Additionally, she
reports that she is brought back to the traumatic event everytime
they try to be intimate, and when they go out in public she has a fear
of being assaulted again. Currently, she is unable to return to where
she previously worked, a clothing store, and feels like her life was
stolen from her.
Past Psychiatric History:
• General statement: Reported that she has never been under
treatment
• Current Caregivers: Parents
• Hospitalization history: Denies
• Medication history: None
• Psychotherapy/Previous Pychiatric Diagnosis: K.A. has never
been diagnosed with any psychiatric disorders or been using
psychotherapy. Victim of sexual assault 7 months ago.
Substance Current use: Reported ocassional alcohol use when
going out with friends but denies cigarette smoking, or other illicit
drugs.
Family Pyschiatric history: Denies. Reports no other history and
denies any history of suicide in the family.
Social history: K.A. was born in Stockton, California, and raised
, Anca Popa
GNRS 534
there by both parents. She has one younger sister who lives with
them. She does not have any children. She worked at a clothing
store till the sexual assault, 7months ago. Hobbies: used to hang out
with friends, and boyfriend, painting and swimming.
Past Medical history: Reports no chronic illnesses. Reports regular
menses, denies taking any type of contraceptives and denies being
sexually active for the past 6 months.
Past Surgical history: Denies.
Medications: none
Allergies: No food/medication allergies. No seasonal allergies.
Spiritual history: Catholic
Immunizations: All vaccinations are up to date
Primary Care Physician: Patient does not see a physician regularly
since she is afraid to go out.
ROS:
General : K.A. denies fever, generalized weakness, or chills.
HEENT:
Head, neck, lymph: Denies any pain or discomfort.
Nose, sinuses: Denies pain. No epistaxis or rhinorrhea.
Throat, mouth, pharynx: Denies pain or difficulty with
swallowing.
Neuro: Denies dizziness, numbness or tingling. Reports being
unable to sleep and difficulty concentrating.
Pulm: Denies congestion or dyspnea. Denies cough.
Cardio / vascular: Denies chest pain. Denies cough or dyspnea on
exertion. Denies any palpitations or heart murmurs.
GI / Abdomen: Denies any nausea, vomiting, diarrhea or
constipation. Denies any epigastric or abdominal pain.
G/U: K.A. denies burning with urination, hematuria, frequency,
dysuria, vaginal discharge or incontinence.
Objective
This is where the Vital Signs
“facts” are located. BP: 115/76 HR: 83 RR: 18 SPO2: 97% T: 98.5
Pain: 0/10
Include relevant labs,
Height: 5’6 Weight: 140 BMI: 22.6 (normal)
test results, vitals, and Diagnostic results:
Review of Systems PTSD Symptom Scale Self-Report Version (PSS-SR):15
(ROS) – if ROS is CBC: normal
negative, “ROS TSH: normal
noncontributory,” or Blood alcohol content (BAC): normal
“ROS negative with
Mental Status examination
the exception of…”
Include MSE, risk
K.A. is a young Hispanic female, who seems to be the stated age,
assessment here, and
dressed appropriately and clean but fidgety and restless. She
psychiatric screening appeared very tense, looking towards the door many times and
measure results. shifting in her chair. She seemed attentive, has good communication
GNRS 534
PTSD (F43.1)
Criteria Clinical Notes
Subjective CC: Family stated …you’ve been afraid to leave the house.” Or “ I
Include chief can’t go out”
complaint, subjective HPI: K.A. is a 22-year-old Hispanic female who presented to the
information from the clinic for evaluation because her family has been stating that she is
patient, names and afraid to leave the house. She reported that she feels uncomfortable
relations of others and threatened by unfamiliar places and people, and that she only
present in the feels safe at home when her family is around. She is afraid of being
interview, and basic alone after the sexual assault, 7 months ago. She reports
demographic nightmares, and re-experiencing the traumatic event over and over
information of the and waking up screaming. K.A. states her boyfriend, Josh, helps her
patient. HPI, Past relax when she wakes up crying from these nightmares by holding
Medical and her and assisting her back to sleep. She states she is a terrible
Psychiatric History, person because of her inability to get out of the house without the
Social History. help of her family (dad, mom, or sister), or her boyfriend, and when
at home she is irritable, cries a lot, and she cannot function normally.
K.A. reports that their relationship and sexual life are affected by her
sense of guilt, and her feelings of being tainted. Additionally, she
reports that she is brought back to the traumatic event everytime
they try to be intimate, and when they go out in public she has a fear
of being assaulted again. Currently, she is unable to return to where
she previously worked, a clothing store, and feels like her life was
stolen from her.
Past Psychiatric History:
• General statement: Reported that she has never been under
treatment
• Current Caregivers: Parents
• Hospitalization history: Denies
• Medication history: None
• Psychotherapy/Previous Pychiatric Diagnosis: K.A. has never
been diagnosed with any psychiatric disorders or been using
psychotherapy. Victim of sexual assault 7 months ago.
Substance Current use: Reported ocassional alcohol use when
going out with friends but denies cigarette smoking, or other illicit
drugs.
Family Pyschiatric history: Denies. Reports no other history and
denies any history of suicide in the family.
Social history: K.A. was born in Stockton, California, and raised
, Anca Popa
GNRS 534
there by both parents. She has one younger sister who lives with
them. She does not have any children. She worked at a clothing
store till the sexual assault, 7months ago. Hobbies: used to hang out
with friends, and boyfriend, painting and swimming.
Past Medical history: Reports no chronic illnesses. Reports regular
menses, denies taking any type of contraceptives and denies being
sexually active for the past 6 months.
Past Surgical history: Denies.
Medications: none
Allergies: No food/medication allergies. No seasonal allergies.
Spiritual history: Catholic
Immunizations: All vaccinations are up to date
Primary Care Physician: Patient does not see a physician regularly
since she is afraid to go out.
ROS:
General : K.A. denies fever, generalized weakness, or chills.
HEENT:
Head, neck, lymph: Denies any pain or discomfort.
Nose, sinuses: Denies pain. No epistaxis or rhinorrhea.
Throat, mouth, pharynx: Denies pain or difficulty with
swallowing.
Neuro: Denies dizziness, numbness or tingling. Reports being
unable to sleep and difficulty concentrating.
Pulm: Denies congestion or dyspnea. Denies cough.
Cardio / vascular: Denies chest pain. Denies cough or dyspnea on
exertion. Denies any palpitations or heart murmurs.
GI / Abdomen: Denies any nausea, vomiting, diarrhea or
constipation. Denies any epigastric or abdominal pain.
G/U: K.A. denies burning with urination, hematuria, frequency,
dysuria, vaginal discharge or incontinence.
Objective
This is where the Vital Signs
“facts” are located. BP: 115/76 HR: 83 RR: 18 SPO2: 97% T: 98.5
Pain: 0/10
Include relevant labs,
Height: 5’6 Weight: 140 BMI: 22.6 (normal)
test results, vitals, and Diagnostic results:
Review of Systems PTSD Symptom Scale Self-Report Version (PSS-SR):15
(ROS) – if ROS is CBC: normal
negative, “ROS TSH: normal
noncontributory,” or Blood alcohol content (BAC): normal
“ROS negative with
Mental Status examination
the exception of…”
Include MSE, risk
K.A. is a young Hispanic female, who seems to be the stated age,
assessment here, and
dressed appropriately and clean but fidgety and restless. She
psychiatric screening appeared very tense, looking towards the door many times and
measure results. shifting in her chair. She seemed attentive, has good communication
