NRNP 6635 Assignment: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD

 

Subjective:

CC (chief complaint): “I don’t want to go anywhere. I just stay in my room all day afraid to sleep. It is bad”.

HPI: P.F. is a 27 year old male who is is a combat Veteran that served in the Marines and separated from active duty less than a year ago, who has come to seek psychiatry help at the insistence of his fiancé. Patient reports that things and events that may appear mundane and ordinary to other people invoke strong memories of his war time experience and cause strong reactions that are alarming to him, as well as those around him. Patient recalls certain sights, smells and sounds make him feel he is “right back in the middle of enemy fire”

Past Psychiatric History:

• General Statement: Patient reports he is afraid to sleep and the extreme reactions he has are beginning to affect his entire life.
• Caregivers : Patient has a fiancé who demanded he seek Psychiatric help.
• Hospitalizations: No previous Hospitalizations.
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: No previous history

Substance Current Use and History: Patient has no history of substance abuse.

Family Psychiatric/Substance Use History: Father has a history of Alcohol abuse  and paternal Grandfather who was also a combat veteran, has a history of depression.

Psychosocial History:

Patiient is currently a furniture sales man but left active service less than a year ago, afte

r long tours of duty in war zones. He is engaged to be married (no date set) and is currently working as a furniture salesman. Patient denies drug and alcohol use, has a fiancé whom he lives with, and his parents and 2 siblings live in a different state.

Medical History:

 

• Current Medications: None indicated but patient has service connected Asthma
• Allergies: Seasonal Allergies

• Reproductive Hx: N/A

ROS:

• GENERAL: Anxious looking male who is well dressed for the season. No weight loss, no fever, no chills.
• HEENT: No visual loss, no hearing loss, no sneezing , coughing, no complaints of sore throat.
• SKIN: No rash, no itching
• CARDIOVASCULA: No chest discomfort, no irregular heart beat.
• RESPIRATORY: Even and unlabored except when reliving past traumas
• GASTROINTESTINAL: Patient complains of occasional nausea when he is reliving war time experirnces.
• GENITOURINARY: No burning on urination, no hematuria.
• NEUROLOGICAL: No headache, occasional dizziness, no numbness, no paralysis
• MUSCULOSKELETAL: No muscle pain, no back pain.,
• HEMATOLOGIC: No bleeding, bruising
• LYMPHATICS: No enlarged nodes
• ENDOCRINOLOGIC: No polyuria, no polydypsia. Diaphoretic when reliving traumatic events

Objective:

Physical exam: N/A

Diagnostic results: N/A

Assessment:

Mental Status Examination: Patient is alert and oriented to person, place, time and situation, speech is clear and coherent, appropriate response to questions. Patient shows signs of anxiety, and appears desperate for answers to his extreme reactions to triggers of his war time experiences. No suicidal ideations, but patient finds it difficult to sleep and has nightmares when he manages to sleep.

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Differential Diagnoses:

Post Traumatic Stress Disorder(PTSD)

This patient is a combat Veteran and so it is easy to draw a conclusion of PTSD as a diagnosis, but specific criteria have to be met before this diagnosis can be made. This patient has experienced traumatic events that happened to him and others during his career as a combat veteran and certain triggers make him react and relive these memories.

As explained by Carlat, D. (2016), all the classic signs and symptoms experienced by PTSD patients including flashbacks, nightmares, hyperarousal, and intense distress when exposed to events that are symbolic of the original event, are evident with this patie

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