Post-Traumatic Stress Disorder

HISTORY:

‍Emotional distress for ‍ ‍hoursdays

Onset: ‍gradualsudden, started after a traumatic event: ‍

‍intrusive memories

‍avoidance of reminders of traumatic event

‍negative changes in thinking and mood

‍changes in physical and emotional reactions

‍difficulty maintaining close relationships

‍feeling emotionally numb

‍lack of interest in activities

‍difficulty experiencing positive emotions

‍difficulty concentrating

‍difficulty sleeping

‍irritability

‍aggressive behavior

‍always being on guard for danger

‍self-destructive behavior

‍overwhelming guilt or shame



Impact on daily activities: ‍minimal

Treatments tried: ‍none, ‍effectiveineffective



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU



EXAM:

Mental Status:

Appearance: ‍well-dressed, ‍well-groomed, ‍goodpoor eye contact, appears ‍age-appropriate

Behavior: ‍cooperativenon-cooperative

Psychomotor activity: ‍normalretardedagitated

Speech: ‍clear, ‍slowrapid, ‍monotonoustalkative

Mood: ‍euthymicdysthymic, ‍anxious, ‍

Affect: ‍euthymic, ‍reactivenon-reactive, ‍full range, ‍appropriate to situation, ‍congruent with mood

Thought process: ‍organizeddisorganized, ‍coherentincoherent, ‍logicalillogical, ‍

Thought content: ‍normalpreoccupationshopelessness, ‍delusions, ‍suicidal ideations, ‍homicidal ideations

Perception: ‍normal, ‍hallucinations, ‍illusions

Cognition: ‍alert, oriented to ‍3 spheres, attention ‍intactdistractible, memory ‍intactimpaired

Judgment: ‍goodmoderatepoor

Insight: ‍goodmoderatepoor into condition

Reliability: ‍goodmoderatepoor



ASSESSMENT:

‍Post-Traumatic Stress Disorder ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍TSH, ‍LFTs, ‍creatinine, ‍electrolytes

- Psychoeducation about PTSD (e.g. symptoms, triggers, coping strategies)

- Regular exercise

- Sleep hygiene

- Avoidance of alcohol and drugs

- Cognitive behavioral therapy

- ‍Antidepressants

- ‍Atypical antipsychotics

- ‍Prazosin

- Eye movement desensitization and reprocessing (EMDR)

- Referral to psychologist

- Referral to social worker

- Referral to psychiatrist

- Follow-up in ‍ ‍weeksmonths

- Return if condition worsen or if new symptoms develop such as suicidal thoughts