Provide additional information to the presentation, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient other than that mentioned in presentation Question asked by presenter What are some effective nonpharmacologic strategies you have used or seen used to help adolescents manage PTSD symptoms other than that mentioned in the presentation? Presented by Kevin the following soap note. HPI: D.J. is a 16-year-old Black American male. He came for a mental health evaluation due to nightmares, anxiety, and trouble sleeping. He was referred by his school counselor after he shared that he feels unsafe and often scared. D.J. says his symptoms started when he was 10 years old. He grew up in a violent home and community. He witnessed his father’s siblings belng slaughtered. He often saw beatings and fights in his home. He still has flashbacks and panic attacks when he hears loud noises. His sleep is poor, and he wakes up in fear. He avoids crowds and feels angry most days. He says, “I try to stay calm by smoking weed. I quit vaping. I want to stop using weed too, but it’s hard.” He reports feeling sad and scared often. He says he doesn’t trust people easily and gets very jumpy. Substance Ciirrent Use: Patient smokes marijuana in secret, about 1 pack (approx. 7 joints) a week. Last use was three days ago. He quit vaping last month. He denies alcohol use. No history of IV drugs, snorting, or other substanccs. No past seizures, tremors, or withdrawal symptoms. Family History: Father- a chain smoker and alcoholic recently diagnosed with Liver cirrhosis. Mother- diagnosed with Post Partum Depression (PPD) after the birth of my younger sister. Paternal grandfather: diagnosed with Genaralized anxiety Disorder and panic attacks. Medical History: None reported at this time. Current Medications: He does not take any prescription, OTC, or herbal medications. Allergies: Pcanuts — causes swelling and trouble breathing (anaphylaxis). Shell fish — causes itchy skin and vomiting. Noknown medication or environmental allergies. Reproductive Hx: Not sexually active. No history of sexual concerns. No sexual trauma reported. ROS: GENERAL: D.J. says he feels tired and isn’t sleeping well. He denies any weight loss, fever, or chills. HEENT: 1-Ie denies having headaches or any recent head injuries. He has no issues with blurry or double vision and reports no eye pain or redness. D.J. denies any hearing problems, nasal congestion, sore throat, or runny nose. SKIN: He mentions his skin gets itchy after eating fish. He denies having any rashes or dry skin otherwise. CARDIOVASCULAR: He reports no chest pain or irregular heartbeats. RESPIRATORY: He denies any shortness of breath, coughing, or wheezine. GASTROINTESTINAL: He has no nausea, vomiting, constipation, or stomach pain. His appetite is normal. GENITOURINARY: D.J. reports no issues with urination. Denies any burning, urgency, or increased frequency. NEUROLOGICAL: He says he feels a bit jumpy but denies dizziness, numbness, or seizures. MUSCULOSKELETAL: He denies any joint or muscle pain. HEMATOLOGIC: No problems with easy bruising or bleeding. LYMPHATICS: He denies any swollen glands and has no history of spleen removal. ENDOCRINOLOGIC: D.J. reports no problems with hot or cold sensitivity, and no unusual thirst or urination. Objective: Vital Signs: Temp: 36.6°C, B.P: 118/74 mmHg, HR: 82 bpm, RR: 16 bpm, O,Saturation: 98% on room air, Ht: 5’7″, Wt: 134 lbs, BMI: 21.0 (Normal weight) Diagnostic results: PCL-5 (PTSD Checklist for DSM-5): Score = 52. The patient’s score of 52 shows significant trauma-related symptoms, including flashbacks, hypervigilance, emotional numbing, and avoidance which indicates probable PTSD. PHQ-9 (Patient Health Questionnaire): Score = 16: Moderate depression symptoms are present but are trauma-related. GAD-7 (Generalized Anxiety Disorder Scale): Score = 13: Suggests moderate anxiety. These symptoms overlap with trauma responses. Urine Drug Screen: Positive for THC: Indicates current cannabis use, which the patient admits is a coping mechanism for trauma symptoms. No imaging or labs were conducted during this visit. Assessment: Mental Status Examination: D.J. is a 16-year-old African American male who appears his stated age. He is dressed appropriately, though his hygiene is average. He is cooperative but maintains limited eye contact and sits in a guarded posture. He appears anxious and distracted. Speech is soft, slow, and clear. Thought processes are logical and goal-directed, but he frequently returns to themes of fear, trauma, and violence. His mood is “sad and scared,” and his affect is flat and restricted. He denies hallucinations or delusions. No signs of thought disorder are present. He is oriented to person, place, and time. His memory is intact, though attention and concentration are mildly impaired. Insight is partial; he knows he is struggling but cannot fully connect his symptoms to past trauma. Judgment is limited, especially regarding substance use. He denies active suicidal or hoinicidal ideation. He does admit to past passive thoughts of “not wanting to wake up,” but he has no current intent or plan. A safety plan was created and reviewed. Diagnostic Impression: Post-Traumatic Stress Disorder (PTSD): According to the DSM-5-TR, PTSD can develop after a person goes through or witnesses a life-threatening event, serious injury, or sexual violence (APA, 2023). In D.J.’s case, he witnessed the violent murder of his father’s siblings and grew up in a home where violence was a regular part of life. He shows clear signs of PTSD as outlined by the DSM-5-TR. This includes intrusion symptoms such as recurring flashbacks and nightmares about the trauma. He also avoids anything that reminds him of what happened like crowds or loud noises. There are negative changes in mood and thinking, including emotional numbness, feeling distant from others, trouble trusting people, and frequent anger (Avanci et a1., 2021). D.J. also has hyperarousal symptoms, like being on edge, easily startled, and having trouble sleeping. These symptoms have been going on for years and have seriously affected how he functions day to day. Tn addition, D.J.’s high score on the PCL-5 assessment supports the diagnosis, showing that his symptoms are clinically significant. His personal history of trauma, emotional withdrawal, and being constantly on alert (hypervigilant) further confirm the PTSD diagnosis. He does not show any signs of psychosis and currently denies having thoughts of harming himself or others, which helps rule out other serious mental illnesses. Major Depressive Disorder (MDD), Moderate, F33.1 D.J. also shows some symptoms of depression. Thcsc include feeling sad, having low energy, trouble sleeping, and difficulty concentrating. These symptoms partly match the DSM-5-TR criteria for Major Depressive Disorder (MDD), which includes at least five symptoms such as a depressed mood, loss of interest in activities, changes in sleep or appetite, low energy, poor concentration, feelings of worthlessness, and thoughts of death or suicide (APA, 2023). However, D.J.’s depressive symptoms appear to be directly linked to his trauma. He doesn’t report losing interest in things he used to enjoy, and he doesn’t consistently feel hopeless unless he is reminded of the trauma. He also does not have any current thoughts or plans of suicide. While his PHQ-9 score suggests moderate depression, the underlying cause seems to be PTSD. So, while depression is present, it is likely a response to trauma, not a separate or primary diagnosis (Maalouf et al., 2022). Generalized Anxiety Disorder (GAD), F4l.1: D J. has also reported some anxiety symptoms. These include being easily irritated, having trouble sleeping, and worrying often. These signs are partly consistent with the DSM-5-TR criteria for Generalized Anxiety Disorder (GAD), which involves excessive anxiety and worry that occur more days than not for at least six months, along with symptoms such as restlessness, fatigue, irritability, muscle tension, sleep problems, and trouble concentrating (APA, 2023). However, D.J.’s anxiety is not about avariety of everyday things, like school, health, or the future. Instead, it is directly related to his traumatic experiences (Maalouf et a1., 2022). The anxiety started after the violcnt events in his life, not before, and he doesn’t have a long history of worrying about unrelated topics. Because of this, GAD does not fully explain his symptoms, and it is not considered the main issue. Diagnostic reasoning: PTSD is the most accurate and supported diagnosis for D J. He meets all the DSM-5-TR criteria, and his symptoms have been confirmed through clinical assessments and observation. While he does show signs of depression and anxiety, these seem to come Lom his trauma and do not appear to be separate mental health disorders. The clinical judgment was based on reviewing the symptoms, understanding when and how they began, and matching them with known patterns from the DSM-5-TR. PTSD best explains D.J.’s struggles and is the primary diagnosis. Reflections: I agree with my preceptor’s assessmentof PTSD as the primary diagnosis.The symptoms clearly align with the DSM-5-TR criteria (APA, 2023). His trauma history, intrusive thoughts, avoidance, emotional numbness, and hypervigilance all support this. Maalouf ct al. (2022) reveals that depression and anxiety arc present in most PTSDA cases but they were linked to trauma, not separate conditions as in D.J’s case. I also agree with the treatment plan as highlighted by Mansour et a1. (2023) of starting trauma-focused therapy and considering SSRIs for mood support.This case helped me understand how trauma in early life can deeply affect mental health. I learned how PTSD can present in young people, especially those exposed to family vlolence. The patient’s trauma symptoms were clear, but they were mixed with signs of depression, anxiety, and substance use. This showed me that it is important to explore the root cause, not just the symptoms. The patient uses marijuana to cope with fear and stress. I realized that substance use in teens is often a sign of deeper emotional pain. If I could conduct this session again, I would focus more on building a stronger therapeutic relationship from the start. The patient was guarded and hesitant to share. I believe spending more time on trust-building and using trauma-informed communication would help him feel safer (Reece, 2020). I would also screen earlier for substance use and discuss how marijuana use may worsen PTSD symptoms over time. Encouraging open dialogue around this without judgment could help him consider treatment sooner. I would also involve a social worker to support the family and llnk them to resources. Legally and ethically, treating a minor with sensitive issues like drug use requires careful handling (Cruz et al., 2023). While parental involvement is necessary, confidentiality must be respected to maintain trust. Social factors play a big role. He lives in a violent area, has a father with liver disease, and a mother with mental illness. These increase his risk. Addressing about his living conditions and maybe seeking for safer enevironment with nothing that reminds him of his past would be a mjor step towards his recovery. Health promotion should focus on trauma care, substance abuse education, and emotional support. Prevention should begin with early intervention and family therapy. Case Formulation and Treatment Plan: The plan for this adolescent focused on trauma recovery, substance use reduction, and emotional support. Psychotherapy was recommended as the main treatment. He was referred to trauma-focused cognitive behavioral therapy (TF-CBT), which is effective in treating PTSD in adolescents (Mansour et al., 2023). Weekly sessions were recommended to help himprocess trauma, build coping skills, and reduce flashbacks and avoidance behavior. A key health promotion as guided by Mansour et al. (2023) activity included daily journaling to help him recognize emotional triggers and express feelings safely. He was also educated on how marijuana may worsen sleep problems and emotional instability over time. He was encouraged to reduce use and to talk honestly during therapy. For pharmacologic treatment, Sertraline 25 mg PO daily was started with plans to increase to 50 mg after one week if tolerated. SSRIs are first-line medications for PTSD and depression in youth. Side effects such as nausea, dizziness, or sleep changes were discussed (Gasparyan ct al., 2022). He and his guardian were advised not to stop the medication abruptly. Nonpharmacologic approaches included referral to a school counselor, family therapy, and support from a youth mentor program. He was also encouraged to get regular sleep, eat well, and exercise to help manage stress naturally. A follow-up visit was scheduled in two weeks to monitor symptoms and medicationtolerance. Safety planning was reviewed. A major social determinantaffecting his mental health is community i iolence. This has led to ongoing fear and trauma. A referral was made to a local youth outreach center that provides support groups, trauma recovery programs, and mentorship for teens affected by violence.
******CLICK ORDER NOW BELOW TO GET THE ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION*******."
