DOCUMENT 7

Week #4: Assessing and Diagnosing Patients with PTSD

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint): The patient presents in the healthcare with complaints of fear of the external environment, insomnia, losing appetite, and feeling that he wants to be by himself.

HPI: P.F., a 27-year-old White male, presents at the healthcare facility for psychiatric evaluation of PTSD. He is not under any psychotropic medications and he has been asked to visit the healthcare facility by his fiancee who has been witnessing the signs of PTSD on the patient. The patient denies any feelings of suicide ideation. However, the patient indicates that his paternal grandfather, a veteran, also feels depression some of the time.

Past Psychiatric History:

· General Statement: This is the first time that the patient is seeking treatment for any psychological disorder.

· Hospitalizations: The patient has not been hospitalized. He indicates that it is his first time to present to a healthcare facility with a psychological issue.

· Medication trials: The patient has not been administered with any psychotic medication. His PCP referred him for a psychiatric test before administration of any psychotic medications.

· Psychotherapy or Previous Psychiatric Diagnosis: The patient has not been diagnosed with any psychological disorder before.

Substance Current Use and History: The patient denies any history of substance abuse and alcohol.

Family Psychiatric/Substance Use History: His father has diabetes mellitus, hypertension, and liver disease. His paternal grandfather who is also a veteran experiences depression some of the time. His mother takes care of his father as he is a drunkard.

Psychosocial History: The patient joined the military immediately after finishing high school and he took part in three long tours of duty in war zones which have lasted for eight years. He has two sisters, one who is older than him and one who is younger than him. Currently, he is a furniture salesperson and he moved to another state as his fiancee got an opportunity there. He has no history of any legal issues.

Medical History: Service-connected asthma

· Current Medications: Currently not taking any medication

· Allergies: Seasonal allergies

· Reproductive Hx: Heterosexual as he has a female fiancee

ROS:

· GENERAL: No significant weight gain or weight loss. The patient’s temperature is normal. The patient indicates that he has insomnia, and he experiences different triggers that make him remember his experiences in war.

· HEENT: The patient denies any visual loss, double vision, or blurred vision. Denies any pain or discomfort in the ears and throat. The patient does not have any pain or injury in the neck.

· SKIN: The patient denies any problems with his skin.

· CARDIOVASCULAR: The patient does not admit to any pain or discomfort in the CV. The patient does not have any history of cardiovascular disease.

· RESPIRATORY: The patient denies any pain or discomfort at the time of examination.

· GASTROINTESTINAL: The patient denies having nausea, anorexia, diarrhea, or vomiting. She denies any abdominal pain or blood. There are no changes in her bowel movements

· GENITOURINARY: The patient does not have any history of STDs or HPV. She is heterosexual.

· NEUROLOGICAL: The patient indicates that he has insomnia, does not want to move out of the house to ab=void any triggers and he feels unsafe.

· MUSCULOSKELETAL: The patient denies back pains, muscle pains or joint pains, and stiffness.

· HEMATOLOGIC: No history of transfusion, lesion removal, skin cancer, and bleeding disorders.

· LYMPHATICS: No enlarged nodes

· ENDOCRINOLOGIC: No reports of heart intolerance.

Objective:

Physical exam: T - 97.4, P - 84, R - 18, BP - 134/88, Ht 5’8”, Wt 167lbs

Diagnostic results: The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) was used to identify whether the patient has PTSD. The results of the test were 27 indicating that the patient has PTSD.

Assessment:

Mental Status Examination: The patient looks like his stated age. He was cooperative alert during her interactions with the psychiatric healthcare practitioner. However, he broke down at times when telling his story and he did not want to remember his time of service. It seemed that there are a lot of triggers in his life that remind him about the negative occurrences during his service. He is neatly groomed and has dressed appropriately according to the weather. The patient’s speech was normal most of the time. He denied any auditory or visual hallucinations. He also denied suicidal ideation. The patient has an above-average concentration as he was struck by thoughts as he was talking thus reducing his concentration.

Differential Diagnoses:

Posttraumatic stress disorder - It is an anxiety psychological disorder that may occur in people who have witnessed or experienced a traumatic event such as an accident, war/combat, natural disaster, a terrorist act among others. The diagnosis was supported by the signs and symptoms that the patient presented. It was supported by internal reminders of events, avoidance of external reminders, altered anxiety state, and changes in mood and thinking (Kessler et al., 2017).

Acute stress disorder - It is an intense, dysfunctional, and unpleasant reaction beginning after an overwhelming traumatic event and lasting than a month. In this case, the diagnosis was ruled out because the symptoms have persisted for more than a month (Bryant, 2017).

Obsessive-compulsive disorder. This is an anxiety disorder in which people have recurring unwanted thoughts, sensations, or ideas that make them feel driven to do something repetitively (Abramowitz & Reuman, 2020).

Reflections: I agree with the preceptor’s diagnostic impression and assessment. The assessment uses the data that is collected from the patient to make an informed diagnosis. If I would do the assessment again, I would ensure that a full body assessment of the patient is conducted. That can help to identify other areas that may be affected by the issue. Ethical considerations were made during the assessment. The patient data that was collected was maintained at high levels of confidentiality. Additionally, the patient was involved in the diagnostic process.

References

Abramowitz, J. S., & Reuman, L. (2020). Obsessive compulsive disorder. Encyclopedia of personality and individual differences, 3304-3306.

Bryant, R. A. (2017). Acute stress disorder. Current opinion in psychology, 14, 127-131.

Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Benjet, C., Bromet, E. J., Cardoso, G., ... & Koenen, K. C. (2017). Trauma and PTSD in the WHO world mental health surveys. European journal of psychotraumatology, 8(sup5), 1353383.