name: Mr. Newsome
age: 19years
gender: male
ethnicity: Caucasian
subjective data
Chief Complaint: intense feeling of terror for two months
History Of Presenting Illness: Mr. Newsome is a 19-year-old male at the emergency department with a concern of persistent and overwhelming worry about the future, which has been affecting their daily life. The symptoms began in the last two months when he discovered he was being activated with Navy reserves. The patient describes how their excessive worry has progressed from occasional concerns to a constant preoccupation with what might go wrong in the future. In addition to excessive worry, the patient may describe a variety of physical and psychological symptoms, such as restlessness, muscle tension, fatigue, difficulty concentrating, irritability, and sleep disturbances. These symptoms often worsen during periods of heightened worry.
Past psychiatric history: the patient denies previous diagnosis of mental diseases.
Medication trials and current medications: he has no record of psychotropic use and he is not on any treatment.
Psychotherapy or previous psychiatric diagnosis: the patient denies attending psychotherapy sessions and psychiatric diseases.
Pertinent substance use: he denies the use of drugs and alcohol.
Social History: the patient lives in Columbus, OH with his dog Chance, he is single and has never married. his parents live locally. he works as a part-time in construction. he has no history of legal issues. he has a good appetite and sleeps for 8 hours.
Family History: he is the only child in his family. his parents are alive without a record of illness. he denies a family history of mental illness and chronic diseases.
Allergies: the patient has no known food or drug allergies.
Review Of Systems
General: the patient denies fatigue, weakness, fever, and unexplained weight loss.
Skin: he denies skin rashes, itching, bruising, or lesions.
HEENT: The patient denies headaches, vision changes, eye pain, hearing problems, tinnitus, vertigo, nasal congestion, rhinorrhea, sore throat, dental issues, or changes in taste or smell.
Cardiovascular System: the patient denies chest pain or discomfort, palpitations, irregular heartbeats, swelling in the extremities, and changes in blood pressure.
Respiratory System: the patient denies shortness of breath, cough, sputum production, wheezing, and chest pain.
Gastrointestinal System: he denies appetite changes, nausea, vomiting, and abdominal pain.
Genitourinary: the patient denies urinary frequency, urgency, dysuria or incontinence.
Neurological: the patient denies headaches, dizziness, and seizures
Musculoskeletal: the patient denies joint pain, muscle pain, stiffness, and weakness.
Hematologic: the patient denies excessive bleeding, easy bruising, or history of anemia or blood disorders.
Lymphatics: the patient has no enlarged nodes.
Endocrinologic: the patient denies thirst, excessive sweating, changes in hair or nail growth.
Objective Data
General: the patient is calm and oriented to time, place, and person.
Vitals: the temperature is at 97.0, pulse rate is at 70, respiratory rate is at 18, blood pressure at 116/68mmHg, height at 5’9, and weight at 175Ibs
Mental State Examination
The patient appears tense, restless, or agitated, with signs of physical discomfort such as fidgeting, pacing, or muscle tension. He exhibits avoidance behaviors, such as avoiding eye contact or withdrawing from social interactions. The patient describes his mood as anxious, worried, or fearful. The thought process is characterized by racing thoughts, excessive worry, or preoccupation with concerns related to their activation or deployment. The content of the patient’s thoughts may revolve around themes of danger, harm, or catastrophic events related to their military service. His cognitive functioning is intact because he has good decision-making and problem-solving skills. his insight is intact because he fully recognizes the impact of their anxiety on their daily life. The patient’s speech is rapid, pressured, and difficult to follow, reflecting their inner restlessness and anxiety.
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