Posted: December 9th, 2022

This is a 24-year-old male with psychiatric hx

Paper should be at least 150 words. Use at least one scholarly source to connect your response to national guidelines and evidence-based research in support of your ideas. Use inside citation. All sources must be referenced and cited using APA Style, including a link to the source.

Mirko,

Chief Complaints: nightmares, flashbacks, intrusive thoughts, panic attacks, worsening depression, irritability, and social withdrawing
History of Present Illness:
This is a 24-year-old male with psychiatric hx of depression diagnosed this year and medical hx of two traumatic brain injuries in the past year during military deployment. Patient presents to clinic c/o worsening depression with addition of new sx of irritability, social withdrawing, nightmares, flashbacks, and intrusive thoughts of combat and explosion which killed several members of his unit while he was driving. Patient also states one episode of a panic attack while driving, which has led him to avoid driving. States current medication from PCP include bupropion and ativan for panic attacks, which he reports as ineffective. Patient comes to clinic with worsening depression and new symptoms of irritability, social withdrawal, nightmares, flashbacks, and intrusive thoughts of combat and an explosion that killed several members of his unit while he was driving. The patient also mentions having a panic attack while driving, which has caused him to avoid driving. Current PCP medication for panic attacks includes bupropion and ativan, which he reports as ineffective.
Assessment:
Patient’s presentation is consistent with Post-Traumatic Stress Disorder (ICD F43.1) based on +direct exposure to life-threatening traumatic event, +sx of flashbacks, nightmares, and panic related to cues resembling traumatic event, +avoidance of stimuli associated with event, +negative mood AEB fear, anger, guilt, social withdrawal, and irritability occurring for more than 1 month which impair social and occupational areas of functioning (U.S. Department of Veteran Affairs, 2013).
Differential includes r/o Post-Concussion Syndrome (ICD F07.81) as symptoms may overlap with PTSD. Patient may be experiencing emotional alterations (depression, irritability, anxiety) related to TBI (Robert, 2020).
Plan:
1. Psych:
• Initiate Sertraline 25 mg PO daily
• Conduct Post-Concussion Symptom Scale (PCSS) and PTSD Symptom Scale Interview (PSS-I and PSS-I-5)
• Connect with outpatient therapy resources (prolonged exposure, cognitive processing therapy, trauma-focused CBT)
• Gather collateral as able
2. Medical
• Review medical chart for hx of TBI to understand severity and evidence of possible severe damage
(Robert, 2020; Watkins et al., 2018)
Sources:
Robert, S. (2020). Traumatic brain injury and mood disorders. The mental health clinician, 10(6), 335–345. https://doi.org/10.9740/mhc.2020.11.335
U.S. Department of Veteran Affairs. (2013, June 6). PTSD and DSM-5. PTSD: National Center for PTSD. Retrieved December 5, 2022, from https://www.ptsd.va.gov/professional/treat/essentials/dsm5_ptsd.asp Links to an external site.
U.S. Department of Veteran Affairs. (2010, March 17). Traumatic Brain Injury and PTSD. PTSD: National Center for PTSD. Retrieved December 5, 2022, from https://www.ptsd.va.gov/understand/related/tbi_ptsd.asp Links to an external site.
Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A Review of Evidence-Based Psychotherapy Interventions. Frontiers in behavioral neuroscience, 12, 258. https://doi.org/10.3389/fnbeh.2018.00258

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