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GNRS 534
PTSD (F43.1)
Criteria Clinical Notes Subjective (^) CC : Family stated …you’ve been afraid to leave the house.” Or “ I can’t go out” HPI : K.A. is a 22-year-old Hispanic female who presented to the clinic for evaluation because her family has been stating that she is afraid to leave the house. She reported that she feels uncomfortable and threatened by unfamiliar places and people, and that she only feels safe at home when her family is around. She is afraid of being alone after the sexual assault, 7 months ago. She reports nightmares, and re-experiencing the traumatic event over and over and waking up screaming. K.A. states her boyfriend, Josh, helps her relax when she wakes up crying from these nightmares by holding her and assisting her back to sleep. She states she is a terrible person because of her inability to get out of the house without the help of her family (dad, mom, or sister), or her boyfriend, and when at home she is irritable, cries a lot, and she cannot function normally. K.A. reports that their relationship and sexual life are affected by her sense of guilt, and her feelings of being tainted. Additionally, she reports that she is brought back to the traumatic event everytime they try to be intimate, and when they go out in public she has a fear of being assaulted again. Currently, she is unable to return to where she previously worked, a clothing store, and feels like her life was stolen from her. Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History. Past Psychiatric History :
- General statement: Reported that she has never been under treatment
- Current Caregivers: Parents
- Hospitalization history: Denies
- Medication history: None
- Psychotherapy/Previous Pychiatric Diagnosis: K.A. has never been diagnosed with any psychiatric disorders or been using psychotherapy. Victim of sexual assault 7 months ago. Substance Current use : Reported ocassional alcohol use when going out with friends but denies cigarette smoking, or other illicit drugs. Family Pyschiatric history : Denies. Reports no other history and denies any history of suicide in the family. Social history : K.A. was born in Stockton, California, and raised
GNRS 534
there by both parents. She has one younger sister who lives with them. She does not have any children. She worked at a clothing store till the sexual assault, 7months ago. Hobbies: used to hang out with friends, and boyfriend, painting and swimming. Past Medical history : Reports no chronic illnesses. Reports regular menses, denies taking any type of contraceptives and denies being sexually active for the past 6 months. Past Surgical history : Denies. Medications : none Allergies : No food/medication allergies. No seasonal allergies. Spiritual history : Catholic Immunizations: All vaccinations are up to date Primary Care Physician : Patient does not see a physician regularly since she is afraid to go out.
ROS :
General : K.A. denies fever, generalized weakness, or chills. HEENT: Head, neck, lymph: Denies any pain or discomfort. Nose, sinuses: Denies pain. No epistaxis or rhinorrhea. Throat, mouth, pharynx: Denies pain or difficulty with swallowing. Neuro: Denies dizziness, numbness or tingling. Reports being unable to sleep and difficulty concentrating. Pulm: Denies congestion or dyspnea. Denies cough. Cardio / vascular: Denies chest pain. Denies cough or dyspnea on exertion. Denies any palpitations or heart murmurs. GI / Abdomen: Denies any nausea, vomiting, diarrhea or constipation. Denies any epigastric or abdominal pain. G/U: K.A. denies burning with urination, hematuria, frequency, dysuria, vaginal discharge or incontinence. Objective Vital Signs BP: 115/76 HR: 83 RR: 18 SPO2: 97% T: 98. Pain: 0/ Height: 5’6 Weight: 140 BMI: 22.6 (normal) Diagnostic results: PTSD Symptom Scale Self-Report Version (PSS-SR): CBC: normal TSH: normal Blood alcohol content (BAC): normal Mental Status examination K.A. is a young Hispanic female, who seems to be the stated age, dressed appropriately and clean but fidgety and restless. She appeared very tense, looking towards the door many times and shifting in her chair. She seemed attentive, has good communication This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results.
GNRS 534
GAD F41.
DSM- 5 Criteria for GAD includes:
- Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities
- Difficulty controlling the worry
- Anxiety associated with 3 of the following 6 symptoms: muscle tension, fatigue, concentration difficulties, restlessness or feeling on edge, irritability and sleep disturbance. The anxiety and worry cause significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance cannot be attributed to substance abuse or other condition. Plan Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment. Treatment /Plan
- The treatment plan for K.A. includes:
- Psychotherapy: Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR) can be beneficial for managing PTSD symptoms.
- Medication: Consider starting the patient on an SSRI such as Sertraline or Paroxetine, which are first-line treatments for PTSD.
- Follow-up: Schedule a follow-up appointment in 4 weeks to assess the patient's response to treatment. If symptoms persist or worsen, consider a referral to a psychiatrist for further evaluation and treatment.
- Educate patient that the antidepressant Sertaline (Zoloft), is a selective serotonin reuptake inhibitors (SSRIs) and typically takes 4-6 weeks to exert its full therapeutic effect. Inform K.A., that some patients can see improvements in 2 weeks, and that it is essential during this period to monitor any side effects, assess the effectiveness of the medication, and make adjustments if needed. Provide patient with a handout on SSRIs, including instructions, benefits, and expected and serious side effects. Ensure the patient knows how to access crisis hotlines and local resources if they experience a mental health crisis References:
GNRS 534
American Psychiatric Association. (2022). Diagnostic and statistical Manual of Mental Disorders, text revision (5th ed.). American Psychiatric Association. Carlat, D. (2017). The psychiatric interview (4th ed.). Philadelphia Wolters Kluwer.
