A 24-year-old male veteran comes to the office for evaluation of chronic knee pain. He has no other medical history. He takes naproxen for knee pain due to an old athletic injury and says that he borrowed some oxycodone/acetaminophen from a friend on 2 occasions when the pain was particularly severe. He requests a prescription for pain medication "just in case the pain does not improve. I used to work in construction and I can't be in pain or I won't get a job." The patient has been unable to find steady employment since returning from his last deployment and worries about providing for his wife and 2-year-old son. He discloses that he has been drinking more when he feels depressed and can't sleep. The patient has difficulty both falling and staying asleep and problems concentrating. He feels guilty for not wanting to spend time with his son and for punching a hole in the wall during a recent argument with his wife. His appetite is unchanged and he has no suicidal ideation. Physical examination is unremarkable. Which of the following is the most appropriate next step in management of this patient?

Question

A 24-year-old male veteran comes to the office for evaluation of chronic knee pain.  He has no other medical history.  He takes naproxen for knee pain due to an old athletic injury and says that he borrowed some oxycodone/acetaminophen from a friend on 2 occasions when the pain was particularly severe.  He requests a prescription for pain medication "just in case the pain does not improve.  I used to work in construction and I can't be in pain or I won't get a job."  The patient has been unable to find steady employment since returning from his last deployment and worries about providing for his wife and 2-year-old son.  He discloses that he has been drinking more when he feels depressed and can't sleep.  The patient has difficulty both falling and staying asleep and problems concentrating.  He feels guilty for not wanting to spend time with his son and for punching a hole in the wall during a recent argument with his wife.  His appetite is unchanged and he has no suicidal ideation.  Physical examination is unremarkable.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c05d_67ac_8f63_3bb544d0b93c_MD0005_00 This patient's history of military deployments and symptoms of depression, sleep disturbance, impaired concentration, angry outbursts, and emotional detachment raise concern for post-traumatic stress disorder (PTSD). Patients with PTSD may try to avoid discussing past trauma and minimize their symptoms. Military personnel, in particular, may be reluctant to disclose PTSD symptoms due to stigmatization and fear of professional repercussions. Primary care physicians should be especially alert to screening for PTSD in returning veterans and individuals experiencing new-onset anxiety, insomnia, interpersonal conflicts, or escalating substance use. Screening to elicit symptoms of PTSD includes inquiring about disturbing memories, nightmares, and flashbacks of traumatic events and assessing for symptoms of hypervigilance, amnesia, and avoidance. Patients with PTSD frequently use substances to self-medicate symptoms and are at high risk for developing substance use disorders. (Choice A) Although the patient exhibits some symptoms of depression, it would be premature to initiate antidepressant treatment without screening him for PTSD. Optimal management of PTSD includes trauma- focused psychotherapy in addition to pharmacotherapy. (Choice B) Over time, it would be important to inquire further about the patient's anger, impulse control, and violence in the home. However, asking to speak with the wife alone before rapport is established and a full assessment is made would be inappropriate and could damage the physician-patient relationship. (Choice C) Support programs for veterans may be helpful but would not substitute for screening for PTSD. If further inquiry supports a PTSD diagnosis, the patient should be referred for comprehensive mental health services. (Choice D) This patient's alcohol use and possible misuse of pain medications require further evaluation, but referral to a rehabilitation program is premature. Substance use disorders are commonly comorbid with PTSD and must be addressed concurrently for optimal outcomes. Educational objective: Physicians should be alert to the possibility of post-traumatic stress disorder (PTSD) in veterans reporting new-onset insomnia, substance use, and interpersonal conflicts. Optimal treatment of PTSD involves a combination of trauma-focused psychotherapy and medication. References: Posttraumatic stress disorder in veterans and military personnel: epidemiology, screening, and case recognition. (http://www.ncbi.nlm.nih.gov/pubmed/23148803) Investigation of abbreviated 4 and 8 item versions of the PTSD Checklist 5. (http://www.ncbi.nlm.nih.gov/pubmed/27137973) Treating veterans and military families: evidence based practices and training needs among community clinicians. (http://www.ncbi.nlm.nih.gov/pubmed/27155870)

A 24-Year-Old Male Veteran Comes to the Office for Evaluation