Subj PTSD - oBJECTIVE DATA FOR DCE MENTAL HEALTH PDF

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Summary

oBJECTIVE DATA FOR DCE MENTAL HEALTH...

Description

5/26/2021

Focused Exam: PTSD | Completed | Shadow Health

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Focused Exam: PTSD Results | Turned In Mental Health Nursing - January 2021, (2021_spring_c16_term)__nu309ka1 Return to Assignment (/assignments/453679/)

Your Results

Reopen (/assignment_attempts/8851145/reop Lab Pass (/assignment_attempts/8851145/lab_pass

Overview

Subjective Data Collection: 39 of 39 (100.0%)

Transcript Subjective Data Collection Hover To Reveal...

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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Objective Data Collection Education & Empathy QSEN Competencies Documentation Care Plan

Category

Scored Items

Program Competency Progress

Patient Data Not Scored

Reflections

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Student Survey

A combination of open and closed questions will better patient data. The following details are facts patient's case.

Chief Complaint

Established chief complaint

Reports sleep problems

History of Present Illness

Asked about onset and frequency of sleep problems

Asked about sleep quality and characteristics

Reports sleep problems for the past 10+ years Reports having problems sleeping most nights the week

Reports recent sleep problems include nightmares Reports falling asleep often takes more than an hour Reports waking up two or three times during th 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 bed "around midnight," but feeling "too nervous" to sleep Reports actually falling asleep at 2 or 3 AM Reports checking her windows and doors twice before going to bed Reports no screen use before bed

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Support

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1/5

5/26/2021

Focused Exam: PTSD | Completed | Shadow Health Reports average wake time of 7 AM 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 sle problems

Past Medical History

Asked about existing health conditions

Reports hypertension diagnosis

Followed up on hypertension diagnosis

Diagnosed 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 PTS diagnosis

Followed up on onset of PTSD

Reports diagnosis age 35 Reports PTSD cause is military sexual assault Reports MST was at age 23 Reports event involved commanding officer an 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 o self-care Reports therapy dog helps Reports smoking helps Reports avoiding stimulating environments whe anxious or stressed

Asked about suicidal ideation and self-harm

Reports occasional feelings that "sometimes I feel like life 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

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Denies past suicide attempts

2/5

5/26/2021

Focused Exam: PTSD | Completed | Shadow Health

Asked about homicidal ideation

Asked about previous psychiatric hospitalizations

Denies homicidal ideation

Denies past psychiatric admissions

Home Medications

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 medications Denies missing doses of medication Denies missing doses of medication because o side effects 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

Followed up on medication for hypertension

Reports taking losartan Reports losartan dosage: 100 mg Reports losartan frequency: 1x daily Denies losartan side effects

Followed up on medication for anxiety

Reports taking buspirone HCL Reports buspirone HCL dosage: 30 mg Reports buspirone HCL frequency: 15mg pill twice daily Denies buspirone HCL side effects Reports taking buspirone HCL 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

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3/5

5/26/2021

Focused Exam: PTSD | Completed | Shadow Health Social History

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

Followed up on cigarette smoking

Reports cigarette smoking

Reports smoking 3 - 4 cigarettes a day Reports started smoking in her early twenties Reports quitting on and off over the last 20 yea

Asked about living situation, safety, and support system

Reports being single Reports living alone but has service dog Reports feeling safe at home

Asked about activity level and exercise

Reports moderate activity level Reports 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 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 mor than she should Denies eating a low-salt diet

Asked about appetite

Asked about last menstrual period

Reports loss of appetite

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 ye ago

Review of Systems

Asked about general symptoms

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Reports weight gain

4/5

5/26/2021

Focused Exam: PTSD | Completed | Shadow Health Denies fever Denies chills Denies night sweats

Followed up on weight gain

Reports gaining 20 lbs 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 headaches Denies syncope, dizziness, fainting, or vertigo Denies changes in coordination Denies changes in memory Denies recent falls

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