Psychiatry Consult

Patient Identification:
- Name: Emily
- Gender: female

History of Presenting Illness:
Emily reports experiencing recurrent nightmares almost every night, which leave her feeling exhausted upon waking. She describes an increase in daytime anxiety, which she finds difficult to manage. Emily also reports persistent fatigue and a lack of motivation, stating that even small tasks feel overwhelming. These symptoms have been ongoing and are significantly impacting her daily functioning and quality of life.

Past Psychiatric History:
Emily is currently being treated with sertraline at a dose of 100 milligrams for her symptoms.

Medications:
Sertraline 100 milligrams daily.

Mental Status Examination (MSE):
Emily appears alert and oriented. Her mood is described as anxious and fatigued, with a congruent affect. Speech is normal in rate and tone. Thought processes are logical and goal-directed. No evidence of psychosis or suicidal ideation is observed. Insight and judgment are intact.

Impression and Recommendations:
Emily's symptoms are consistent with post-traumatic stress disorder (F43.10) and generalized anxiety disorder (F41.1). The recurrent nightmares and daytime anxiety are significantly impairing her functioning and quality of life. Initiated prazosin at a low dose to address trauma-related nightmares and improve sleep quality. Maintained the current dose of sertraline at 100 milligrams daily. Educated Emily on potential side effects of prazosin, including dizziness and the possibility of worsening dreams, and advised her to report any adverse effects promptly. Scheduled a follow-up appointment in two weeks to assess the effectiveness of prazosin and monitor symptoms. Encouraged Emily to reach out earlier if she experiences concerning side effects or worsening symptoms.