*NURSING > SHADOW HEALTH > Shadow Health -Nicole Diaz- PTSD-updated 2021 (All)
Nicole Diaz- PTSD Chief Complaint Finding: Established chief complaint Finding: Reports sleep problems (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they ar... e presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: What are your symptoms? History of Present Illness Finding: Asked about onset and frequency of sleep problems Finding: Reports sleep problems for the past 10+ years (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have a history of sleep problems? Finding: Reports having problems sleeping most nights of the week (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How long have you been having sleep problems? Finding:Asked about sleep quality and characteristics Finding: Reports recent sleep problems include nightmares (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What wakes you up at night? Finding: Reports falling asleep often takes more than an hour (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How long does it take for you to fall asleep? Finding: Reports waking up two or three times during the night for "at least ten minutes" (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How often do you wake up during the night? Finding: Reports waking in the morning feeling "out of it" and not rested (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How do you feel when you wake up in the morning? Finding: Reports frequent snoring (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you snore? Finding: Asked about sleep habitsFinding: Reports going to bed "around midnight," but feeling "too nervous" to sleep (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What is your sleep like? Finding: Reports actually falling asleep at 2 or 3 AM (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What time do you fall asleep? Finding: Reports checking her windows and doors twice before going to bed (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What do you usually do before bed? Finding: Reports no screen use (television or computer) before bed (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you use the computer or watch TV before you go to sleep? Finding: Reports average wake time of 7 AM (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What time do you wake up? Finding: Reports sleeping an average of 4 or 5 hours a night (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help youfollow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How much sleep do you get a night? Finding: Reports sleeping alone in a quiet room (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Can you describe where you sleep? Finding: Asked about patterns for sleep problems Finding: Reports that stress and anxiety exacerbate sleep problems (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What makes it harder for you to sleep? Past Medical History Finding: Asked about existing health conditions Finding: Reports hypertension diagnosis (Found) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Q [Show More]
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