Post-Traumatic Stress Disorder

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍emotional distress

Onset was ‍gradualsudden, started after a traumatic event: ‍

Symptoms include:

‍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 is ‍minimal

Alleviating factors: ‍none, ‍effectiveineffective



Contributing factors:

‍past traumatic events

‍physical or sexual abuse

‍unstable family relationships

no history of: ‍PTSD, ‍depression, ‍anxiety disorders, ‍substance use disorders

no family history of: ‍mental health issues



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, disoriented to ‍, attention ‍intactdistractible, memory ‍intactimpaired

Judgment: ‍goodmoderatepoor

Insight: ‍goodmoderatepoor into condition

Reliability: ‍goodmoderatepoor





ASSESSMENT:

‍Post-Traumatic Stress Disorder ‍likelysuspectedpossible

DDx: acute stress disorder, adjustment disorders, anxiety disorders, depressive disorders, personality disorders, substance use disorders, bipolar disorder, dissociative disorders, psychotic disorders, somatic symptom disorder, personality disorder, borderline personality disorder, intermittent explosive disorder, traumatic brain injury, sleep disorders, malingering, factitious disorder





PLAN:

Investigations:

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

Treatments:

- 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)

Further care:

- 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