Focused Exam PTSD Completed Shadow Health documentation

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Focused Exam: PTSD Results | Turned In C487 Psych/Mental Health Clinical - Aug 2018, C487 Return to Assignment Your Results Reopen Lab Pass Documentation / Electronic Hea... lth Record Flowsheets Documentation Nursing Admitting Note Student Documentation Model Documentation Chief Complaint not being able to sleep, trouble following asleep 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 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. 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 Home Medication losartan once a day buspirone wellbutrin Buspirone HCL 15 mg b.i.d. for anxiety, last dose this morning Bupropion HCL (12H) 150 mg b.i.d. for depression, last dose this morning Losartan 100 mg daily for blood pressure, last dose this morning Family History mother cervical cancer father died of coranary heart disease, history of stroke, unknown neck lump Cervical cancer in mother at 36; father had neck lump - type unknown age 50's; no family history of diabetes, MI, stroke. Father deceased of coronary heart disease; mother still living. Education and work: Currently retired (military disability); served 10 years in the US Air Force as an airplane mechanic; sexual assault by a commanding officer; service connected for PTSD related to military sexual trauma (MST); bachelor’s degree in English. Religion: Actively involved in a Catholic church in Shadowville. Social History four cigarettes a day rarely drinks alcohol diet cosisting primarily of takeout Living situation and family: Nicole lives alone with her service dog. Her family does not live in the area but she remains in contact with her family members. She has close friends through her church. She dated a man from her church but broke it off when they became too close. Diet: Nicole does not like to cook for herself so she eats out a great deal. She eats sometimes to calm her nerves Substance use: Morning coffee only, rare alcohol, 3- 4 cigarettes a day Exercise: Nicole walks her dog daily; she used to ride her bicycle on local bike trails until she became uneasy about being on the trails alone. Since she got her service dog, she does not ride her bicycle. Student Documentation Model Documentation GENERAL: Negative for fever, chills, night sweats, fatigue; unintentional weight gain of 30 pounds past 2 years; BMI 31.6 (current weight is 181 pounds ) RESPIRATORY: Negative for shortness of breath CARDIOVASCULAR: Negative for chest pain, edema; blood pressure 142/90, occasional palpitations Review of Systems unremarkable GASTROINTESTINAL: Negative for abdominal pain, vomiting, constipation, diarrhea, nausea NEUROMUSCULAR: Negative for weakness, fainting, numbness/tingling, dizziness, falls, or changes in coordination or memory or headaches MENTAL HEALTH: history of anxiety and depression; occasional suicidal thoughts without history of suicide attempts; quick temper, sleep disturbance most nights--- difficulty falling and staying asleep, nightmares several nights a week, daytime fatigue; feels too nervous to fall asleep, checks her windows and doors several times before going to bed.Rates current depression at 4 on scale of 1-10 with 10 being worst. Denies suicidal thoughts today Mental Status Note Student Documentation Model Documentation Appearance clean, well kept normal for age Ms. Diaz is a 48-year-old Cuban American woman of average height. She appears overweight. Eye contact is direct. Her expression is tense and posture rigid. Her clothing is appropriate to her age and occasion. She appears well groomed. Attitude cooperative, engaged, open, relaxed Ms. Diaz is cooperative, but is anxious and appears guarded when asked about her social history. Motor Activity lack of eye contact, flat facial expression, no involuntary movements Ms. Diaz's motor activity appears agitated. She has a clenched jaw and clenched fists. She has a steady gait and continuous steps. Speech normal rate, volume, quantity, and fluidity Ms. Diaz's speech is rapid and she only responds to questions when asked. No observed problems with liveliness, volume intensity, or flow. Her speech is normal for her age, education, and general ability. Student Documentation Model Documentation Mood and Affect easily angered, obessive thoughts, sudden modd changes Ms. Diaz is guarded and appears to be moderately anxious. Her affect is appropriate to the situation but constricted. She appears stable. She is aware that she is anxious and tense. Thought Process normal Ms. Diaz's thoughts have no observable disordered behaviors. Her thoughts appear coherent, logical, and relevant. Thought Content suicidal thoughts, dpressve state, obessive thoughts Ms. Diaz has some passive suicidal ideation, reporting that she is not sure she can go on like this anymore because of her exhaustion and tension from PTSD. She appears paranoid, stating that she checks her doors and windows multiple times before she goes to sleep at night. She cannot sleep deeply because of her paranoia and fears. Perceptual Disturbances none Ms. Diaz has no delusions or hallucinations. There are no observable abnormal tendencies. Orientation and Level of Consciousness a/o x 3 A&O x 4 Cognition no noted difficencies No problems with serial 7s or abstract reasoning. Her memory appears normal and she is attentive and aware of the situation. Insight normal [Show More]

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