Posted: January 5th, 2023
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Experts selected these topics as essential components of a strong, thorough interview with this patient.
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Established chief complaint
Reports sleep problems
Asked about onset and frequency of sleep problems
Reports sleep problems for the past 10+ years
Reports having problems sleeping most nights of the week
Asked about sleep quality and characteristics
Reports recent sleep problems include nightmares
Reports falling asleep often takes more than an hour
Reports waking up two or three times during the 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 (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
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
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 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 Nicole Diaz PTSD shadow health Subjective Data Collection
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