Treatment Plan and Notes: K.A.C. is a 67-year-old male patient who was presented to the clinic accompanied by his two sons. K.A.C. reports that he has been experiencing some strange dreams and experiences for a while.

 
Treatment Plan and Notes:
K.A.C. is a 67-year-old male patient who was presented to the clinic accompanied by his two sons. K.A.C. reports that he has been experiencing some strange dreams and experiences for a while. However, of late, these dreams and experiences are almost life-like and leave him feeling afraid. His sons note that he sometimes shouts and begs for his life in his sleep. Small knocks shock him, and sometimes he is ready to fight. K.A.C. is a former U.S. Army officer deployed six times during his service years. He notes that he was captured and held as a prisoner of war post-Gulf War between 1991 and 1993. The current symptoms have been severe since they were attacked by armed robbers at their house two months ago, and K.A.C. was held at gunpoint.

K.A.C. was openly anxious and distressed throughout the evaluation. He said he feels his old nightmares are back and real this time. He notes that there are some people out to detain him. He is majorly hypervigilant. Besides his previously diagnosed high blood pressure (HBP) and type 2 diabetes mellitus (T2DM), K.A.C. has no other health or mental concerns. From the symptoms presented and reports on health history, with reference to the DSM-5 TR, K.A.C. is diagnosed with posttraumatic stress disorder (PTSD).

After a review of his current health status and medication, Sertraline (Zoloft) and prazosin were prescribed to help K.A.C. manage his PTSD episodes. K.A.C. is put on Zoloft 50 mg to be taken orally once daily. The medication will be titrated based on how the symptoms respond to the current dosage as well as how K.A.C. tolerates the medication alongside his current hypertension and T2DM medication plan. He will also use prazosin 1 mg taken orally once daily before bedtime to help with his blood pressure. The prazosin dosage can be gradually increased to 4-12 mg dosage based on how K.A.C.’s blood pressure responds to the medication and how well he tolerates the dosage. K.A.C. will be required to adhere to the T2DM treatment plan. His sons were educated on how to manage and care for their father and were informed of the right medication administration strategies to avoid cases of reactions and adverse unintended outcomes. All related medication risks and side effects were also clearly explained while emphasizing the need to report any reactions to the dosages. For all dosage increases or reductions, the family will be required to consult a specialist and report the progression of the symptoms. K.A.C.’s next appointment is scheduled in the next 14 days at the Geriatric Mental Health Unit.