Focused Exam: PTSD Results | Turned In8/28/2018 Focused Exam: PTSD | Completed | Shadow Health
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Focused Exam: PTSD Results | Turned In
C487 Psych/Mental Heal
...
Focused Exam: PTSD Results | Turned In8/28/2018 Focused Exam: PTSD | Completed | Shadow Health
https://wgu.shadowhealth.com/assignment_attempts/3743701 1/6
Focused Exam: PTSD Results | Turned In
C487 Psych/Mental Health Clinical - Aug 2018, C487
Return to Assignment
Your Results Reopen Lab Pass
Indicates an item that you found.
Indicates an item that is available to be
found.
Catego
ry
Scored Items
Experts selected these topics as essential
components of a strong, thorough interview
with this patient.
Patient Data
Not Scored
A combination of open and closed questions
will yield better patient data. The following
details are facts of the patient's case.
Chief Complaint
Established chief complain00.0%) Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
QSEN Competencies
Documentation
SBAR
Overview video
Reflections
Student Survey
Hover To Reveal...
Hover over the Patient Data items
below to reveal important information,
including Pro Tips and Example
Questions.
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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 (television or
computer) before bed
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 sleep 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
PTSD 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 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
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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 selfharm
Reports occasional feelings that
"sometimes I feel like life is not worth living"
Denies active suicidal ideation or selfharm
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
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 of side effects
Denies difficulty obtaining medications
because of finances
Denies difficulty obtaining medications
because of transportation
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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
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
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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 quitting on and off over the last 20
years
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
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
Review of Systems
Asked about general symptoms Reports weight gain
Denies fever
Denies chills
Denies night sweats
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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
Comments
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