Week 6 Case Study

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WEEK 6 SUMMARY Patient Information: L.K., 33, F, Hispanic, State Insurance Setting : Family Practice in a busy suburban region S CC: Nightmares, waking up at night and screaming, HPI: 33 y/o female presents to clinic with c/o scary nightmare and constant uncontrollable thoughts of a dangerous violence that she witnessed in the street 9 months ago. She is traumatized by the event. She states she does not like talking about it because 'it was horrible'.When she hears loud noise, she panics and hides under table. She does not want to go anywhere. Her husband is the one that does grocery. Current Medications: None Allergies: NKDA PMHx: Childhood/previous illnesses: None Chronic illnesses: None Surgeries: Appendectomy in 2001…show more content…
Appropriate, in NAD. Affect appropriate. Coherent and cooperative. Maintains good eye contact. Husband sitting next to her. HEENT: Head normocephalic and atraumatic. PERRLA, EOMs intact. Noninjected. Fundoscopic exam unremarkable. Ear canal non erythemic, no drainage, TMs intact and clear, pearly grey. No otalgia. Neck supple. No thyromegaly. No lymphadenopathy noted. Skin: intact, no lesions. Normal skin turgor. CV: S1 and S2 RRR, no murmurs, no rubs Pulmn: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, bowel sounds present in all 4 quadrants, no organomegaly. Extremities: No edema , + pedal pulse Neuro: Intact A Primary Diagnosis PSTD (ICD-10-CM – F43.10) – This is an anxiety disorder due to exposure to traumatic events. Symptoms of the disorder include persistent re-experiencing of the event, avoidance of traumatic trigger, hyper activity such as irritability and sleeplessness (Sareen, 2014). Rationale: L.K. is re-experiencing the dangerous street violence that has led to her being fearful and hides when she hears loud sounds. She is sleepless and experiences nightmares. She is experiencing constant flashbacks of the event. Secondary Diagnosis Anxiety disorder , unspecified (ICD-10-F41.9) – This condition is manifested by excessive worry and fear than lasts for more than six months. Some of the symptoms include irritability, sleeplessness, fatigue, muscle tension and shortness of breath (Bystritsky et al., 2013).
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