- The patient is a 40-year-old woman with a history of PTSD from childhood trauma who has been experiencing more symptoms since a recent boating accident. She often copes with alcohol and changes her medications without consulting providers. - She is currently taking citalopram, risperidone, and lorazepam but still experiences flares. Her medications and dosage may need adjustment to better control her symptoms. - A physical exam is also needed since she has not seen her primary care provider in over a year to evaluate any other health concerns.

1. Michelle Widholm
CC: “I’ve been having more flashbacks, flares and dissociative episodes since I was involved in a boating
accident last month.”
HPI:Patient is 40 year old white female with a history of PTSD. This was caused by a traumatic stalking
situation which occurred when she was fourteen years old. During the following eight years she was
drugged and taken advantage of. When was turned 26 she was able to get away and fled to the northwest.
She eventually decided to move back to Boston three years ago to take care of her mother who was ill. At
this time she started experiencing flashbacks and nightmares. When she has PTSD episodes she often
tends to cope by consuming alcohol. These episodes are triggered by people talking to her about her past
trauma, seeing people involved in the incident, and searching for a job. The patient has seen other doctors
before coming to this clinic. She also goes to therapy every two weeks. Since she started on medication
and therapy her symptoms have decreased to a manageable level but she still has flares sometimes.
PMH: H/O Anxiety disorder
H/O PTSD
H/O Smoking
H/O Alcohol abuse
PSH: None
Allergies: No known drug allergies
Past medication trials:
No records from this patient’s previous providers were sent when she started treatment here
approximately one and a half years ago. Her previous provider had her taking risperidone 0.25mg three to
four times a day depending on how bad her symptoms were and lorazepam 0.5mg 1-3 tablets by mouth at
bedtime to help her sleep. She initially had an appointment with her new PCP where she was started on
nicotine 7mg patches. Patient refilled these and continued smoking. Her PCP referred her to the psych
pharmacist at the clinic to continue her PTSD treatment. At the initial appointment no medications were
changed. At her first follow up appointment risperidone treatment was adjusted to 0.25mg three times a
day, the patient was told not to take the extra dose and to take her doses in even eight hour intervals. At
this follow up melatonin 1mg as needed was added to help the patient sleep. Patient noted later that she
started taking all three tablets in the morning and not at even intervals. Melatonin was stopped at her next
appointment because it was not effective. Four months later at another follow up the patient reported
taking her risperidone two tablets in the morning and one at bedtime but noted that this change sometimes
made her feel groggy. A year later she reported taking her risperidone 0.25mg all at bedtime but denied
any morning grogginess. Even though the dose has been constant the patient still had flares and symptoms
though out the last year and a half. Since the patient was still having “PTSD flares” citalopram was added.
The patient noted that she was on citalopram in the past but it did not seem to work. It was determined
that another trial now would be appropriate since we didn’t have records and the patient was not 100%
sure that she had actually been on citalopram. Citalopram 10mg was initiated over a year ago again at the
clinic and since then the patient has been increased to 30mg daily due to continued symptoms.
Trazodone50mg (1/2 tab to 1 tab at bedtime) was initiated a year ago to allow her to decrease her
Lorazepam use. The following month she stated that the nights when she had to take the trazodone it
greatly helped her sleep. However as time went on she started taking the medication less and less. This
was because stating she said it was not longer effective. In her last follow up appointment a few weeks
ago the medication was discontinued. Like stated above, this patient was on lorazepam 0.5mg (1-3 tablets
at bedtime) when she started at the clinic a year and a half ago. At one point she was using the lorazepam
twice a day and at night for most days but she now decreased her use to 1 and ½ tablet at bedtime 1-2
times a week at this time.

2. Michelle Widholm
Current Medications
Citalopram 20mg Take 1 and ½ tablet by mouth daily Qty 45 2 refills
Risperidone 0.25mg Take 1 tablet by mouth three times a day Qty 90 2 refills
Lorazepam 0.5mg Take 1 to 3 tablets by mouth at bedtime Qty 30 0 refills
Proair 108mcg/act Inhale 2 puffs by mouth 4x a day Qty 1 inhaler 3 refills
FH: Patient has a history of ovarian cancer. Her aunt also had breast cancer. There were no family
members with heart disease or diabetes in her family. Mother and father are still alive.
SH: Patient has a history of smoking. It is unclear at this time if she is smoking or not since she has a
history of quitting for a few months and then relapsing. Patient reports living alone with her dog. She
completed her bachelor’s degree and works self employed as a marketer. She is currently going to job
interviews to get a new job and going to graduate school. She is casually dating but is still single. Patient
is G1P0. She was involved in a serious stalking situation where she was drugged at points but denies
taking any drugs willingly. She also binge drinks only when her symptoms flare saying that she does not
feel the urge to drink when her symptoms are controlled. However when the patient drinks she will buy
wine to bring home and drink one or two full bottles at a time. She only drinks these at night when she is
home alone. She has tried to drink socially in the past but it often leads her to drink large amounts at
home alone after leaving her friends. Since she has been at the clinic she has relapsed multiple times.
Patient does go to AA meetings in an attempt to stay sober. This allows her to remain sober for a few
months but is eventually triggered by her symptoms and relapses. At her last appointment she had been
sober for about a month.
ROS: VSS, alert, oriented, fluent in speech without psychotic features or even depressed mood or affect.
Not overly anxious
PE: Vitals from last appointment: HR 61 BP 86/126 T 98.7º Height 5’ 6” Weight 168.9lbs
BMI: 27.3
From her urgent care appointment 7 months ago—she was diagnosed with bronchitis.
o Gen: Complains of fevers, chills, sweats,fatigue, and headache. Denies anorexia, malaise, and
weight loss
o Eyes: Denies blurring, irritation, discharge, vision loss, eye pain, or photophobia
o HEENT: Complains of nasal congestion. Denies earache,ear discharge,tinnitus, decreased
hearing, nosebleeds, sore throat, hoarseness, and dysphagia
o Cardio: Denies chest pains, palpitations, syncope, dyspnea on exertion, orthopnea, or peripheral
edema
o Respiratory: Complains of cough, dyspnea, and wheezing. Denies excessive sputum, and
hemoptysis.
o Gastro: Denies nausea,vomiting, diarrhea, constipation, change in bowel habits, or abdominal
pain
o GU: Denies vaginal discharge, incontinence, dysuria, hematuria, urinary frequency, or
amenorrhea, abnormal vaginal bleeding, and pelvic pain
o Skin: Denies rash, itching, dryness, or suspicious lesions
o Neuro: Complains of vertigo, headache. Denies transient paralysis, weakness,paresthesias,
seizures, syncope, and tremors
o Psychiatric: Denies, depression, anxiety, memory loss, mental disturbance, suicidal ideation,
hallucinations, and paranoia
Labs: Have never been done at the clinic. Patient reports that labs done at her previous provider were all
norm

3. Michelle Widholm
Problem List:
I. PTSD
II. Anxiety and mood liability
III. Alcohol abuse
IV. Physical exam needed
V. Smoking history
VI. Weight management
Patient is a 40 year old female diagnosed with PTSD and anxiety. She is currently still experiencing some
symptoms from her condition and often changes how she takes her medicine without consulting her
providers. She often self medicates with alcohol further exacerbating her disease. To control her
symptoms better medications changes will be made. There are clinical trials in women with PTSD, cause
by similar situations, which support the use of risperidone as monotherapy or as augmentation to anti-
depressant therapy. Schedule, dose, duration and safety all need to be evaluated in this patient. She has
also not seen a primary care provider since she first came to the clinic thus it is impossible to evaluate if
she has other health concerns other than her psychiatric issues.