Anxiety OSCE - PTSD

Diagnosis: PTSD

Case Overview

  • Age/Sex: 54-year-old male
  • Occupation: Accounts clerk (sedentary office job)
  • Setting: GP clinic for assessment of anxiety
  • Chief complaint: "Feeling anxious and on edge"

Patient Script

Who I Am

I'm a 54-year-old accountant who works at a desk all day and I smoke about 10 cigarettes a day.

What Brings Me In

I've been feeling on edge and jumpy for months and it's getting in the way of my work and sleep.

My Story

About 6 months ago I was in a fairly bad road traffic accident — another car hit me from behind while I was driving home from work. I had some bruising and a sore neck at first but nothing that needed surgery. For the first few weeks I felt shaken but seemed to be getting back to normal. Then, starting roughly 2 months after the crash, I began having bad nightmares about the crash and I sometimes wake up sweating. I also get sudden, vivid memories of the accident during the day — it feels like I'm back in the car for a few seconds and my heart races. Loud brakes or horns make me very jumpy and I avoid driving down the road where it happened. I'm on edge all the time, irritable with my wife and find it hard to concentrate at work. I also sleep poorly, getting 3–4 hours before waking, and I feel drained the next day.

I haven't had thoughts of hurting myself, but I worry I might lose my job because I'm distracted and have started calling in sick sometimes. I drink a couple of beers most evenings to try to relax — a bit more than I used to — and I smoke more when I'm stressed.

My Medical Background

  • Past medical history: whiplash/neck strain after the crash; intermittent tension headaches since then
  • Medications: occasional ibuprofen for neck pain; no regular medications
  • Allergies: none known
  • Smoking: 10 cigarettes/day
  • Alcohol: 2–3 beers most evenings (no blackouts); increased since the accident
  • Illicit drugs: denies
  • Family history: father had heart disease; mother alive, history of depression

What I Think & Worry About

  • "I think I might be losing it — why can't I stop thinking about the crash?"
  • "I'm worried my boss will notice I'm not doing my job and I'll get fired."
  • "I hope this isn't something wrong with my heart because my chest tightens sometimes when I get anxious."

If You Ask Me About Other Symptoms...

  • Sleep: "Mostly broken sleep, nightmares about the crash most nights."
  • Mood: "I feel irritable and down sometimes, not enjoying the things I used to."
  • Suicidal thoughts: "No, I haven't had thoughts of hurting myself."
  • Physical: "My neck still bothers me if I sit too long; I get headaches after staring at the screen."
  • Cardiorespiratory: "Sometimes my chest feels tight and my heart flutters when I'm triggered, but it settles after a few minutes." (red herring)
  • Concentration/memory: "I forget small things at work and find it hard to focus on spreadsheets." (could be PTSD or depression)
  • Alcohol/drugs: "I have a couple more beers to try to sleep — nothing heavy and no drugs." (distractor)
  • Functional: "I avoid driving past the junction where it happened and have called in sick a few times because I'm too shaken to go in."

Clinical Summary

Examination

  • General: middle-aged man, alert, appears anxious and mildly hypervigilant, good eye contact
  • Vitals: BP 138/86 mmHg, HR 88 bpm regular, RR 16/min, Temp 36.8°C, SpO2 98% on air
  • Cardiorespiratory exam: heart sounds normal, no murmurs; chest clear to auscultation
  • Neck/MSK: reduced cervical range of motion with tenderness over posterior neck muscles (consistent with chronic whiplash changes)
  • Neurological: grossly intact cranial nerves, no focal deficits, normal coordination
  • Mental state exam: oriented x3; mood anxious and low; affect constricted; thought content without delusions; no current suicidal ideation; describes intrusive memories and nightmares when asked; insight present; attention/concentration reduced on serial 7s

Investigations

  • ECG: sinus rhythm, rate 86 bpm (no ischemic changes) (to assess palpitations/chest tightness)
  • Chest X-ray: clear (no acute cardiopulmonary disease)
  • FBC: Hb 14.2 g/dL, WCC 7.1 x10^9/L, platelets 240 x10^9/L (normal)
  • TSH: 1.9 mU/L (euthyroid)
  • Urea & electrolytes: within reference range
  • Urine drug screen: negative
  • Alcohol use screen (AUDIT-C): 6 (increased use but not severe dependence)
  • Cognitive screen (MoCA/MMSE as available): within normal limits for age (mild attention deficits on testing)

Diagnosis

Primary diagnosis: Post-traumatic stress disorder (PTSD)

  • Evidence: history of exposure to a traumatic event (road traffic accident 6 months ago) with persistent re-experiencing symptoms (flashbacks, nightmares), avoidance of reminders (avoids driving past accident site), negative mood/irritability and concentration problems, and hyperarousal/startle response, lasting more than 1 month and causing occupational/social impairment.

Differential diagnoses:

  • Major depressive disorder: explains low mood, anhedonia, poor concentration, but does not account for re-experiencing, nightmares, and clear trauma triggers.
  • Generalized anxiety disorder: generalized worry could overlap but lacks trauma-specific intrusive memories and avoidance behaviors.
  • Acute stress disorder: timing excluded (symptoms have persisted >1 month since trauma).
  • Traumatic brain injury/post-concussive syndrome: consider if there was loss of consciousness at the time of the crash (patient denies), but persistent headaches and concentration issues necessitate screening if history suggests head injury.
  • Substance-induced anxiety: increased alcohol use may exacerbate symptoms but is not the primary driver given trauma-linked symptoms and negative drug screen.

Management

  • Immediate:
    • Assess safety: explicitly ask about suicidal ideation/intent and plan (patient denies current SI).
    • Provide psychoeducation about PTSD: explain relation to traumatic event and common symptoms.
  • Short-term interventions:
    • Offer referral for trauma-focused psychological therapy (first-line): cognitive behavioural therapy for PTSD (trauma-focused CBT) or eye movement desensitisation and reprocessing (EMDR).
    • Sleep hygiene advice; avoid routine benzodiazepines due to risk of dependence and interference with trauma processing.
    • Advise reduction of alcohol intake; offer brief intervention and consider referral for support if alcohol use increases.
    • Treat comorbid pain: refer to physiotherapy for neck pain and workplace ergonomics.
  • Pharmacological (if moderate-severe symptoms or patient prefers medication):
    • Consider SSRI (e.g., sertraline) as first-line pharmacotherapy for PTSD; discuss benefits/side effects and start under GP/psychiatry guidance.
    • Consider prazosin for distressing nightmares if persistent and after specialist review (local practice dependent).
  • Follow-up:
    • Arrange prompt referral to mental health services/psychology for trauma-focused therapy and review in 2–4 weeks to reassess safety, symptoms, and response to interventions.
    • Liaise with occupational health regarding work adjustments and sick leave if needed.

Key Learning Points

  • PTSD should be considered in patients with trauma history who present with re-experiencing (flashbacks, nightmares), avoidance, hyperarousal, and functional impairment for more than 1 month.

  • Trauma-focused psychological therapies (trauma-focused CBT or EMDR) are first-line treatments; SSRIs are indicated when symptoms are moderate–severe or when psychotherapy alone is insufficient.

  • Rule out and manage medical mimics and contributors (e.g., cardiac causes of palpitations, thyroid dysfunction, substance use) but avoid attributing trauma-specific symptoms solely to these red herrings.

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