Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example

Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example

Subjective:

CC (chief complaint): The individual cannot handle negative situations

HPI: Sergeant Berry Sullivan, a 27-year-old man, came to the clinic for mental examination after serving in the military for eight years and deciding to leave active service in the marines. Mr. Sullivan entered the military shortly after graduating from high school and served three extended tours in various warzones. This implies that the individual has witnessed traumatic events during his active days in the military, considering his long participation in different warzones. The individual highlights that his father is abusive when drunk and that he has never used alcohol and drugs due to his father’s behavior. Mr. Sullivan also indicated that he does not experience any symptoms of anxiety, PTSD, or major depressive disorder.

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Past Psychiatric History:

• General Statement: Mr. Sullivan is a 27 years old man who was brought up in a low-income family with an alcoholic father who was abusive when drunk. The client joined the military immediately after completing high school. He left the military less than a year ago. He visited the facility for psychiatric examination for anxiety, PTSD, and major depressive disorder. He states that his grandfather, who also served in the military, suffered from depression though he never told one.
• Caregivers (if applicable): Not applicable
• Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example
• Hospitalizations: The client has no prior history of psychiatric health or drug abuse therapy. (The health practitioner needs to enquire from the client if he has had any psychiatric health treatment, inpatient mental hospitalization, or intensive outpatient treatment, whether during his time in the military or in the past)
• Medication trials: Not known
• Psychotherapy or Previous Psychiatric Diagnosis: Not known

Substance Current Use and History: Mr. Sullivan reports that he has never used alcohol or any substances in the past.

Family Psychiatric/Substance Use History:  

• Sullivan’s father is a heavy alcohol drinker and engages in abusive behaviors when drunk. Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example
• The client’s paternal grandfather served in the military and reported that he suffered from depression Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example

Psychosocial History: Mr. Sullivan was born in a low-income family to an alcoholic father who was abusive to them when drunk. Currently, the father is diagnosed with various health conditions such as DM, liver cirrhosis, and HTN. Her mother is in good health condition. The client has two siblings, one brother, and one older sister. The family also comprises his paternal grandfather, who was diagnosed with depression. The client served in the military for eight years and currently lives with his fiancé.

Medical History:

• Current Medications: Mr. Sullivan is currently taking asthma medication. The condition is connected to seasonal allergies from his service in the military Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example.
• Allergies: None

• Reproductive Hx: Mr. Sullivan has no children, but they want kids someday.

ROS:

• GENERAL: Mr. Sullivan is attentive and oriented, well dressed, suitably clothed for the weather and event, and does not appear to be in extreme discomfort.
• HEENT: No trauma or head injury.
• SKIN: The client does not have a skin rash or itchy skin
• CARDIOVASCULAR: Mr. Sullivan denies chest pains, discomfort, congestion, and edema in the lower extremities. Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example
• RESPIRATORY: Mr. Sullivan reports that he has difficulty catching his breath.
• GASTROINTESTINAL: Mr. Sullivan has nausea and vomiting.
• GENITOURINARY: The client does not have abnormal urine color and no burning sensation when urinating Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example.
• NEUROLOGICAL: The client does not have any symptoms of neurological conditions.
• MUSCULOSKELETAL: No joint pains or swelling and no muscle pains
• HEMATOLOGIC: No bleeding, no bruising, and no blood infection
• LYMPHATICS: Mr. Sullivan does not have enlarged lymph nodes
• ENDOCRINOLOGIC: The client has no polyuria, polydipsia, or polyphagia

Objective:

Physical exam:

T-98.8

P-86

R-18

B/P-122/7

Ht-5’8

Wt-160lbs

Diagnostic results: The healthcare practitioner should examine the individual for depression and anxiety scores. The doctor should also request the patient undergo a blood test to determine the complete blood count, and thyroid-stimulating hormone Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example.

Assessment:

Mental Status Examination:

Appearance: The individual was well-groomed. Healthcare providers should assess for any odor.

Eye contact: Fair

Speech: The individual had an everyday speech in rhythm and volume.

Behavior: Cooperative and Calm.

Psychomotor: No involuntary motions.

Mood: Depressed.

Thought: Paranoid, organized, goal-directed.

Thought content: No delusions. The provider should ask the individual if he is experiencing self-harm thoughts and suicidal ideation.

Perception: He shows no reaction to external stimuli. This implies that the provider should assess for other signs such as audio-visual hallucinations.

Concentration: The patient portrays signs of sustained attention and concentration.

Cognition: Alert

Memory: The individual shows symptoms of recollection of events which implies that his short-term and long-term memory is not well intact.

Insight: Fair

Judgment: Fair

Fund of Knowledge: Medium

Intelligence: average

Differential Diagnoses:

1. Post-Traumatic Stress Disorder

Post-traumatic stress disorder is a mental disease, which is most common in those who have encountered or seen a traumatic event, such as a natural catastrophe, terrorism, or a serious accident. The condition is associated with various negative symptoms such as trauma memory impairment, low self-esteem, pathological guilt, unpleasant feelings, decreased involvement in activities, alienation, and emotional numbing. Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example Other symptoms experienced by an individual diagnosed with the condition include irritability, aggression, sleep disturbance, and impaired concentration. Thus, PSTD should be ruled in as the mental health issue facing the patient since his Symptoms match those of PSTD.

1. Anxiety Disorder

Anxiety disorder is another condition common mental condition due to extreme stress (Bryant, 2019). This is another type of mental health condition associated with difficulty getting through a typical day due to a high level of anxiety (Koyuncu et al., 2019) Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example. The condition’s primary symptoms include excessive nervousness, rapid palpitations, excessive sweating, shortness of breath, trembling, chest pain, nausea, dizziness, fear of death, insanity, and paresthesias.

1. Major Depressive Disorder

The individual should also be diagnosed with major depressive disorder. This disease is associated with a continuous sense of despair and loss of interest. It mostly affects how a people feel, think, and conduct themselves and can result in a series of expressive and physical difficulties. The main signs and symptoms of the psychiatric condition include depressed mood and loss of interest in activities and pleasures one initially enjoyed.

Reflections:

          The client presented to the clinic and served in the military for eighteen years, highlighting his participation in three long tours of duty in different warzones worldwide. This implies that the individual witnessed the death of many people, including people he knew personally in the military. This case study highlights the trauma that military personnel and veterans experience while serving. According to (Chin & Zeber, 2020), the trauma that military personnel experience during their deployment has a high chance of manifesting in the form of fear and anxiety. Another study by Smith & Hartelius (2020) indicates that different smells and sounds can trigger flashbacks and reactions, which can cause the veterans to avoid places, and things, detach from people, and experience nightmares. As mentioned in the interview, many veterans do not share their stories and the mental problems they experience after serving in the military because the majority believe that taking that step will make them look weak. It takes much courage to open up to other people. This implies that it is essential that individuals surrounding veterans support them and encourage them to seek help. It is also essential to provide veterans with the necessary training and education on recognizing signs and symptoms of mental conditions to seek the relevant help for symptoms management (Waitzkin et al., 2018) Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example. The government should also focus on providing proper and timely resources, services, and support to eliminate the barriers veterans face in seeking mental health treatment.

References

Bryant, R. A. (2019). Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges. World psychiatry, 18(3), 259-269.

Chin, D. L., & Zeber, J. E. (2020). Mental health outcomes among military service members after severe injury in combat and TBI. Military medicine, 185(5-6), e711-e718.

Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in context, 8.

Smith, G. P., & Hartelius, G. (2020). Resolution of dissociated ego states relieves flashback-related symptoms in combat-related PTSD: A brief mindfulness based intervention. Military Psychology, 32(2), 135-148.

Waitzkin, H., Cruz, M., Shuey, B., Smithers, D., Muncy, L., & Noble, M. (2018). Military personnel who seek health and mental health services outside the military. Military Medicine, 183(5-6), e232-e240 Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD Assignment Example.