CASE DESCRIPTION: Peggy is a physically healthy divorced 28-year old Puerto Rican ICU nurse in Washington DC, who is also a member of the U.S. Army Reserves and a marathon runner.

CASE DESCRIPTION: Peggy is a physically healthy divorced 28-year old Puerto Rican ICU nurse in Washington DC, who is also a member of the U.S. Army Reserves and a marathon runner. She presents to her primary care provider (PCP) for assessment of symptoms that began about a week after she returned from witnessing the 2013 Boston Marathon bombings a month ago where she also assisted her fellow runners who were injured. She appears anxious when describing her experience with the assistance efforts. Although she cries when describing the terror and chaos following the bombing and emergency care needed, she is methodical when describing her symptoms, including difficulty sleeping, nightmares, inability to concentrate, irritability, headaches, anxiety, and lack of energy – almost as if they are happening to someone else and not her. Peggy talked about her symptoms with her mother, who shared that she experienced similar symptoms after returning from the war in Vietnam where she served as a nurse. She explained to Peggy that such symptoms occurring in relation to a stressful experience are now identified as post-traumatic stress disorder (PTSD), and encouraged Peggy to see her PCP for evaluation. Among the PCP’s recommendations is a referral for psychotherapy and medication consultation, consideration of pharmacogenomic testing for guiding drug selection, and consideration of participating in clinical research to learn more about PTSD. Peggy’s Family History (as described in the case; all healthy unless otherwise noted)

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• Peggy: age 28, divorced 2 yrs ago (since divorce, headaches, anxiety, anger, lost weight, running helped improve symptoms); no children; c/o symptoms of PTSD; no prior hx of depression; runs 3 x week; difficulty coping after Boston marathon bombing;

• Mother: Rosa, age 63, history of depression, served in the Vietnam War – difficulty returning back to normal (exhibited symptoms of PTSD), received counseling and took meds until 27, when symptoms resolved. Had some side effects when she took medication.

• Father: Pete, age 65

• Siblings: one sister, Eva, age 26

• Maternal Grandmother: Louise, 83, depression at age 71, dementia

• Maternal Grandfather: Edgar, 85, prostate problems

• Paternal Grandmother: Mary, died at age 67, r/t diabetes

• Paternal Grandfather: George, died at age 63, MVA

• Ethnicity: o Maternal: Puerto Rican o Paternal: English

• Religion: Catholic ** Peggy presents with symptoms of PTSD, but has not yet been officially diagnosed. Her mother had symptoms of PTSD after the Vietnam War, but PTSD wasn’t identified yet as a disease. At that time, it was called “shell-shock”. Today, we would call it PTSD. For this case study, it is ok to include diagnoses in the pedigree and key, even if the person has not been “officially” diagnosed. Only include illnesses, not symptoms, in the key.

1) Describe the causes of PTSD. Explain the symptoms and categories of PTSD

2) Describe the risk factors of & the influence of personal/family history on PTSD. Is it hereditary? What genes are involved if any? Why or why not is Peggy at risk?

3) What protection does the Genetic Information Nondiscrimination act (GINA) provide?

4)Explain what protections and lack of protections are provided by GINA. What groups does GINA protect and not protect? What types of insurance does GINA not apply to

5) Does Peggy’s family hx. exhibit any red flagsas defines by the F-GENES red flag list? What are the nursing implications? What should Peggy’s nurse do next?