History of Present Illness: Patient is a 24 year old male. He has been on deployment for the past year where he sustained two traumatic brain injuries and lost several members of his unit during an explosion where he was the driver. Patient has been seen in primary care and treated with bupropion for depression and ativan for panic attacks. Patient has stated that over the past six weeks his mood has gotten worse. He was initially feeling depressed but now he states he has become more irritable and withdrawn. He has experienced nightmares, flashbacks, and intrusive thoughts of combat and the explosion. He also reported panic attacks while driving and has begun to avoid driving.
Assessment: Patient is alert and oriented. Voice is projected and speech is fast paced. Fidgets with hands while speaking. Patient appears irritable, ungroomed and distraught. Eye contact is not engaged.
Treatment Plan:
· Suicidal and homicidal evaluation
· Assess living circumstance and help with securing safe environment
· Enrollment in psychotherapy that uses Gestalt’s therapy
· Medication Regimen based on symptoms. SSRI such as Fluoxetine (Prozac), ativan for abortive treatment of anxiety, melatonin for sleep.
· Needs to be enrolled in either school or work program that allows for him to create productive time within his day
· Enrollment in group setting with others who are going thru PTSD as well
· Follow up appointment to discuss progress in all areas and how medication regimen is working out.
This patient’s treatment plan is based on the person as a whole. The Gestalt therapy has the goal of assisting the patient in restoring their organismic self-regulation system. A medication regimen based on symptoms will help alleviate discomforts while he is working through his mental state. The group therapy sessions can help the patient understand that he is not alone in the journey. There are other people who have experiences similar to his (Wheeler, 2020).
Wheeler, Kathleen. Psychotherapy for the Advanced Practice Psychiatric Nurse. Available from: VitalSource Bookshelf, (3rd Edition). Springer Publishing LLC, 2020.
