Focused Exam: PTSD - Nicole Diaz *Complete
version*
,Comprehensive Focused Exam: Post-Traumatic Stress Disorder (PTSD) – Nicole Diaz
Course: NR 325 – Adult Health II / Mental Health Nursing
Student: [Your Name]
Date: [Insert Date]
1. Patient Demographics & Background
Patient Name: Nicole Diaz
Age/Sex: 29-year-old female
Ethnicity: Hispanic
Marital Status: Single
Occupation: Registered Nurse
Chief Concern: Persistent anxiety, nightmares, hypervigilance following a traumatic event
Past Medical History (PMH):
• Anxiety disorder, diagnosed 3 years ago
• No history of major depression or bipolar disorder
• No chronic medical illnesses
Past Surgical History (PSH):
• Appendectomy at age 21
• No other major surgeries
Allergies:
• NKDA
Medications:
• Sertraline 50 mg daily (SSRI for anxiety)
• Occasional use of lorazepam 0.5 mg PRN for acute anxiety
Family History:
• Mother: Generalized anxiety disorder
, • Father: Hypertension
• Siblings: Healthy
Social History:
• Lives alone
• Non-smoker, no alcohol or illicit drug use
• Support system includes close friends and extended family
Lifestyle & Habits:
• Irregular sleep due to nightmares
• Reports avoiding places or situations that trigger traumatic memories
• Maintains moderate physical activity (walking, yoga)
Immunizations:
• Up-to-date
2. Chief Complaint (CC)
“I keep reliving the accident, I can’t sleep, and I’m always on edge. I feel like I’m losing control.”
3. History of Present Illness (HPI)
Nicole Diaz is a 29-year-old female presenting with persistent anxiety, nightmares, and
hypervigilance following a motor vehicle accident 9 months ago, which resulted in minor
injuries. She reports re-experiencing the trauma through intrusive thoughts and nightmares,
avoidance of driving or being near cars, and heightened startle response.
She also describes difficulty concentrating at work, irritability, and social withdrawal. Symptoms
have persisted for more than six months, causing significant functional impairment.
Associated Symptoms:
• Nightmares 3–5 times per week
• Insomnia, difficulty falling and staying asleep
• Hypervigilance and exaggerated startle response
version*
,Comprehensive Focused Exam: Post-Traumatic Stress Disorder (PTSD) – Nicole Diaz
Course: NR 325 – Adult Health II / Mental Health Nursing
Student: [Your Name]
Date: [Insert Date]
1. Patient Demographics & Background
Patient Name: Nicole Diaz
Age/Sex: 29-year-old female
Ethnicity: Hispanic
Marital Status: Single
Occupation: Registered Nurse
Chief Concern: Persistent anxiety, nightmares, hypervigilance following a traumatic event
Past Medical History (PMH):
• Anxiety disorder, diagnosed 3 years ago
• No history of major depression or bipolar disorder
• No chronic medical illnesses
Past Surgical History (PSH):
• Appendectomy at age 21
• No other major surgeries
Allergies:
• NKDA
Medications:
• Sertraline 50 mg daily (SSRI for anxiety)
• Occasional use of lorazepam 0.5 mg PRN for acute anxiety
Family History:
• Mother: Generalized anxiety disorder
, • Father: Hypertension
• Siblings: Healthy
Social History:
• Lives alone
• Non-smoker, no alcohol or illicit drug use
• Support system includes close friends and extended family
Lifestyle & Habits:
• Irregular sleep due to nightmares
• Reports avoiding places or situations that trigger traumatic memories
• Maintains moderate physical activity (walking, yoga)
Immunizations:
• Up-to-date
2. Chief Complaint (CC)
“I keep reliving the accident, I can’t sleep, and I’m always on edge. I feel like I’m losing control.”
3. History of Present Illness (HPI)
Nicole Diaz is a 29-year-old female presenting with persistent anxiety, nightmares, and
hypervigilance following a motor vehicle accident 9 months ago, which resulted in minor
injuries. She reports re-experiencing the trauma through intrusive thoughts and nightmares,
avoidance of driving or being near cars, and heightened startle response.
She also describes difficulty concentrating at work, irritability, and social withdrawal. Symptoms
have persisted for more than six months, causing significant functional impairment.
Associated Symptoms:
• Nightmares 3–5 times per week
• Insomnia, difficulty falling and staying asleep
• Hypervigilance and exaggerated startle response
