Shadow Health Nicole Diaz- PTSD (2022/2023) Rated A

Shadow Health Nicole Diaz- PTSD (2022/2023) Rated A 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. 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. Denies losartan side effects Followed up on medication for anxiety. Reports taking buspirone HCL. Reports buspirone HCL dosage: 30 mg. Reports buspirone HCL frequency: 15 mg pill twice daily. Denies buspirone HCL side effects. Reports taking buspirone for 1 year. Reports buspirone HCL is effective in reducing anxiety. Followed up on medication for depression Reports taking bupropion HCL. Reports bupropion HCL dosage: 150 mg Reports bupropion HCL frequency: twice daily Denies bupropion HCL side effects Reports taking bupropion HCL for 1 year. Reports taking various antidepressants in the past. Reports bupropion HCL is effective for treating depression. Asked about occupation and education. Reports working as a grant writer. Reports undergraduate degree in English. Asked about illicit drug use Denies illicit drug use. Asked about alcohol use Reports rare alcohol use. Followed up on alcohol use Reports drinking less than once a month. Reports drinking 1-2 drinks in a sitting. Asked about tobacco and nicotine use. Reports cigarette smoking. Followed up on cigarette smoking Reports smoking 3-4 cigarettes a day. Reports started smoking in her early twenties. Reports feeling safe at home. Asked about living situation, safety, and support system. Reports being single. Reports living alone but has a service dog. Reports feeling safe at home. Asked about activity level and exercise. Reports moderate activity level. Reports that past bike riding, although she doesn't ride her bike anymore. Reports walking service dog daily. Reports decreasing activity level. Asked about diet Reports eating mostly carry-out food. Reports breakfast is typically a yogurt. Reports that lunch is typically a sandwich or burger. Reports dinner is typically fast food. Reports enjoying comfort foods when stressed. Denies binge-eating but feels like she eats more than she should. Denies eating a low-salt diet. Asked about appetite Reports loss of appetite Asked about last menstrual period Reports having menstrual periods (has not yet reached menopause). Reports LMP was 2 weeks ago. Reports periods are becoming irregular. Asked about recent sexual activity. Reports not currently sexually active. Reports last sexual activity was more than a year ago. Asked about general symptoms Reports weight gain. Denies fever. Denies chills. Denies night sweats. Followed up on weight gain Reports gaining 20lbs. Reports weight gain occurred over last 2 years. Reports weight gain was unintentional. Asked about review of systems for gastrointestinal Denies nausea. Denies abdominal pain. Denies difficulty swallowing. Denies vomiting. Denies constipation. Denies diarrhea. Denies changes in stool or bowel patterns. Asked about review of systems for neurological Denies weakness. Denies headache. Denies syncope, dizziness, fainting, or vertigo. Denies changes in coordination. Denies changes in memory. Denies recent falls. Education & Empathy: PTSD Model Statement: "PTSD is difficult for anyone who experiences it. Please let me know if I do anything that makes you feel uncomfortable or that triggers your symptoms. Our goal is to make your care here comfortable and a positive experience. I can put you in touch with mental health nurses or trauma counselors if you would like. There are also many support groups for veterans who face the same issues, and I would be happy to refer you to one." Education & Empathy: Patient History Model Statement: "I'm sorry this happened to you. You are a survivor who has come so far. You seem very aware of the impact that this event has had on your life, and I commend you for directly addressing the underlying issues. I am here if you would like to talk more about it, and if there is anything you need, please let me know." Education & Empathy: Suicidal Ideation Model Statement: "When you say that life is not worth living, you are talking about suicide. I understand that you are facing a difficult time with your sleep issues and your history, but we can focus on how to move forward and get you help. I would recommend counseling. I would like to refer you to counseling, and resources like a national suicide prevention hotline." Education & Empathy: Smoking Cessation Model Statement: "I understanding that smoking can be a form of stress relief for you, but smoking could also be making your sleep problems worse. There are healthier forms of stress release, including exercise. Smoking also puts you at risk for high blood pressure and lung disease. We have medications and nicotine replacement products that can help you stop smoking. Quitting smoking is hard, but it is possible. I would like to refer you to someone for help with smoking cessation." Education & Empathy: Poor Sleep Model Statement: "It must be very hard to experience sleep problems. I am sure that having nightmares, and not being able to get a full night's sleep, must be exhausting. We can help find ways to improve your sleep so you can get some rest." Education & Empathy: Exercise Model Statement: "Exercise can be a good way to lower your stress and might help you sleep better. I recommend increasing your exercise routine and going on longer walks with Boomer, or taking up bike riding again or attending a gym a few times a week." Education & Empathy: Diet Model Statement: "I understand that your symptoms and your busy job make it hard to find time to cook. However, take-out food is high in salt and fat, which could contribute to your hypertension and mood. A nutritionist could help you balance your diet and suggest how to prepare simple meals that are healthier."