PTSD
Age: years old
Gender:
HISTORY:
Presents with a - history of
Onset was , started after a traumatic event:
Symptoms include:
Impact on daily activities is
Alleviating factors: ,
Contributing factors:
no history of: , , ,
no family history of:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
EXAM:
Mental Status:
Appearance: , , eye contact, appears
Behavior:
Psychomotor activity:
Speech: , ,
Mood: , ,
Affect: , , , to situation, with mood
Thought process: , , ,
Thought content: , , ,
Perception: , ,
Cognition: , oriented to , disoriented to , attention , memory
Judgment:
Insight: into condition
Reliability:
ASSESSMENT:
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: , , , ,
Treatments:
- Psychoeducation about PTSD (e.g. symptoms, triggers, coping strategies)
- Regular exercise
- Sleep hygiene
- Avoidance of alcohol and drugs
- Cognitive behavioral therapy
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-
-
- Eye movement desensitization and reprocessing (EMDR)
Further care:
- Referral to psychologist
- Referral to social worker
- Referral to psychiatrist
- Follow-up in
- Return if condition worsen or if new symptoms develop such as suicidal thoughts
HISTORY: EXAM: Mental Status: ASSESSMENT: PLAN: