R. is a 24-year-old male who male who recently returned from a combat mission in which he lost several members of his unit

R. is a 24-year-old male who male who recently returned from a combat mission in which he lost several members of his unit

Respond to the post of at least two of your peers with a different approach to the treatment plan. Provide a recommendation for a different medication and therapy and discuss your reasons for choosing this approach.

Post 1

Psychiatric Consultation

History of Present Illness

R. is a 24-year-old male who male who recently returned from a combat mission in which he lost several members of his unit, during an explosion, while he was driving. Ron has been seen by his family practice provider who diagnosed him with depression and started him on bupropion. Ron reported no improvement and began having nightmares, flashbacks, and intrusive thoughts of combat and the explosion. He also reported a panic attack when he was driving and has begun to avoid driving. R. has been prescribed Ativan by his PCP for the panic attacks and was referred to psychiatry for further management. It is recently discovered that Ron has been having progressively worsening symptoms for the past six weeks. Initially he reported he felt depressed, but he is becoming more irritable and withdrawn.

Past Psychiatric History:

Addiction/Substance Use History: Denies. Non-smoker of tobacco products.

Psychiatric Hospitalization: Pt. has never been hospitalized for any psychiatric reasons.

Outpatient Treatment: Pt was receiving treatment from his PCP. He was prescribed Bupropion and Ativan. Pt reported no improvement from the Bupropion and Ativan.

Suicidal/Self Injurious: Denies

Psychotropic Medication History: Pt was diagnosed with depression by his family practitioner provider. Pt was prescribed Bupropion and Ativan. Pt reported no improvement from the Bupropion and started having nightmares.

Diagnoses:

Major Depression Disorder, F33.1

PTSD, F43.1

Assessment

Review of Systems:

  • General:Patient presents with a flat affect. Normal tone of voice and speech. Well-groomed. Skin and nails clean.
  • Endocrine: Patient denies any thyroid issues. Hot and cold tolerance normal.
  • HEENT: Ears without redness and drainage. Patient does not wear glasses or hearing aids. Hearing is adequate. Eyes are clear without redness. Visual acuity is adequate. Nasal passage without drainage. No redness or swelling to throat or tonsils. No swallowing difficulty. Neck without swelling or lumps.
  • Pulmonary: No hx of respiratory issues. Lungs are clear to bases. Patient is on room air. No oxygen use.
  • Cardiovascular:  Patient denies any chest pain. Normal sinus rhythm. No heart murmurs.
  • Gastrointestinal:  Patient denies GI issues. Bowel sounds are normal active x4 quadrants. Abdomen is soft and non-tender to touch.
  • Genitourinary: Patient denies any bladder or urinary problems.
  • Gynecological: None
  • Skin: Skin is clean and Skin color is normal for ethnicity. No rashes, wounds, or lesions.
  • Hematopoietic: Patient denies any bleeding disorders. No hx of anemia.
  • Neurological: Patient is alert and oriented x4. Speech is clear. Coherent. No hx of reported seizures.
  • Musculoskeletal:  Full range of motion. No musculoskeletal issues reported. Patient denies chronic pain issues. Steady gait.
  • Allergic/Immunologic: No known allergies. No seasonal allergies reported.

Mental Status Exam: Patient is alert, oriented x4, and coherent. Speech is clear. Patient presents with a flat affect. Tone is normal. Patient answers questions appropriately. Patient follows subject matter appropriately. Patient can follow directions appropriately. Patient denies having thoughts of harm to self and others. Patient presents with an anxious, guarded, and a withdrawn demeanor.

Physical Exam: Patient reports he sustained two traumatic brain injuries during his last year of deployment. No reported surgeries.

Allergies: NKDA

VS: 132/62, 98.8, 16, 77, 98% O2 on RA

Impression: Patient is 24-year-old male recently Patient does not present with suicidal ideation. Pt is suffering from continued nightmares, flashbacks, and intrusive thoughts of combat and the explosion. Ron has had progressively worsening symptoms for the past six weeks. Initially he reported he felt depressed, but he is becoming more irritable and withdrawn.The patient and this provider agree, for the safety of the patient, that the patient may benefit from continued treatment with this provider. Treatment will be continued for medication management and management of presented and reported symptoms. New medications Paxil and Prazosin to be started. Ativan and Bupropion will be discontinued as patient is reporting worsening symptoms and no relief from these medications.

Plans/Education/Recommendations:

Plan:

  • Labs: UDS, BAL, CBC, WBC, A1C, Lipid panel, TSH, Liver panel
  • Results:Pending
  • Refer patient for imaging (MRI, CAT scan) to assess for any worsening symptoms related to brain injuries.
  • Paxil (Paroxetine) 20 mg daily in am orally with or without food. I did not choose Sertraline at this time due to the side effect of trouble sleeping. Paxil is also FDA approved for PTSD (Le, 2021). Studies have proven that Paroxetine improved PTSD symptoms in 54% to 62% of people (Le, 2021). Paxil helps with anxiety and depressive symptoms as well. Provider will adjust dose as needed and tolerated.
  • Prazosin (Minipress) 1 mg orally at bedtime. Provider will adjust dose as needed and tolerated. Some studies have shown Prazosin to be safe and effective medication in managing nightmares and sleep disturbances in people with PTSD (Peters, 2022).
  • Refer patient to therapist for psychotherapy (CBT) 12 weeks.CBT has been proven to be the most effective psychotherapy for short- and long-term PTSD. CBT focuses on the trauma. CBT will help the patient identify, understand, and change distorted and negative thinking patterns and behaviors (Anxiety & Depression Association of America, 2021).
  • Resources provided for group support therapy if patient prefers individual and/or group therapy.
  • Safety orders: Do not use drugs or alcohol while taking Paroxetine. Avoid driving if feeling drowsy.
  • Lifestyle changes/recommendations: Eat a healthy, well-balanced diet, exercise, meditate, get good rest and sleep, and reduce stressors.
  • Follow up: Follow up with provider two weeks after this initial assessment to assess effectiveness of medications and for any changes in symptoms or mood.
  • Pt is to notify provider if there are any side effects from medication.
  • If having any thoughts of suicide or worsening symptoms, pt agrees to go to the nearest emergency room.

Signature: Sabrina Meza, RN, BSN, PMHNP Student

References:

Anxiety & Depression Association of America. (2021, June). PTSD Facts & Treatment: Anxiety and Depression Association of America, ADAA. PTSD Facts & Treatment | Anxiety and Depression Association of America, ADAA. https://adaa.org/understanding-anxiety/posttraumatic-stress-disorder-ptsd/treatment-facts#:~:text=Psychotherapy,the%20center%20of%20the%20treatment.

Le , K. (2021, July 6). Zoloft, Paxil, and the Most Effective PTSD Medications. GoodRx health. https://www.goodrx.com/conditions/ptsd/best-medica…

Peters, B. (2022, December 17). How Minipress (prazosin) is used for stress nightmares in PTSD. Verywell Health. https://www.verywellhealth.com/prazosin-treats-nig…


Post 2

HPI:

Ron is a 24-year-old male who has recently served in the military and sustained multiple traumatic brain injuries during his deployment. For the past six weeks, he has experienced progressively worsening symptoms, such as depression, irritability, and withdrawal, which have increased in intensity. In addition to this, he has also begun to suffer from nightmares, flashbacks, and intrusive thoughts of the battle and the explosion. As a result of the recent accident he experienced while deployed, he has also been suffering from panic attacks while driving and has begun avoiding driving as much as possible as a result. Bupropion was prescribed for the patient as a treatment for depression, but this did not seem to work for him, and Ativan was also prescribed as a treatment for anxiety.

Assessment:

In light of Ron’s information, he may have post-traumatic stress disorder (PTSD) due to the trauma he endured during his deployment. As well as that, he has also suffered two traumatic brain injuries, which could be exacerbating his symptoms and making it hard to distinguish PTSD symptoms from those of the injuries.

PTSD is plagued and often haunted by unwanted and continuing intrusive thoughts and memories of what happened. He has developed an array of symptoms associated with Post Traumatic Stress Disorder (PTSD), which are often triggered by traumatic experiences such as combat and an explosion while driving, and he is frequently plagued by nightmares and constantly haunted by unwanted and continuing intrusive thoughts and memories associated with the incident.

Treatment Plan:

Ron’s treatment plan is recommended to focus on treating his PTSD symptoms and encourage him to consult his physician to rule out any complications that may result from the TBI. It is recommended that pharmacotherapy, as well as psychotherapy, should be combined for the treatment of Ron’s PTSD symptoms to achieve the best possible outcome. Pharmacotherapy options for treating PTSD are anti-depressants such as selective serotonin reuptake inhibitors (SSRIs), anti-anxiety medications, and Prazosin. First-line treatment for PTSD includes selective serotonin reuptake inhibitors (SSRIs): sertraline, paroxetine, and fluoxetine, as well as selective serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine. There are currently only two drugs approved by the Food and Drug Administration (FDA) for treating post-traumatic stress disorder (PTSD): sertraline (Zoloft) and paroxetine (Paxil).

I recommend that Ron take sertraline (Zoloft) at 50 mg daily and follow up in 2 weeks regarding any side effects he may experience. The other thing I recommend to Ron is that he begin psychotherapy therapy as soon as possible. Several psychotherapy options are available to treat PTSD, including cognitive behavior therapy, exposure therapy, and eye movement desensitization and reprocessing (EMDR). Exposure therapy aims to help you face situations and memories that are frightening to you, so you can learn how to cope with them effectively. Exposure therapy has been beneficial for people who experience flashbacks and nightmares. The most appropriate treatment for Ron would be a combination of pharmacotherapy with an SSRI and exposure therapy, which would help him manage his symptoms. It is also recommended that Ron be seen for weekly individual exposure therapy sessions to help him process the trauma and address any other issues related to the trauma.

Brady, K., Pearlstein, T., Asnis, G. M., Baker, D., Rothbaum, B., Sikes, C. R., & Farfel, G. M. (2000). Efficacy and safety of sertraline treatment of posttraumatic stress disorder: A randomized controlled trial. Links to an external site. Journal of the American Medical Association, 283, 1837-1844.

Mayo Foundation for Medical Education and Research. (2022, December 13). Post-traumatic stress disorder (PTSD). Mayo Clinic. Retrieved April 12, 2023, from https://www.mayoclinic.org/diseases-conditions/pos…


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