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Comprehensive Psychiatric Evaluation Of a Patient with Post-Traumatic Stress Disorder Essay

Comprehensive Psychiatric Evaluation Of a Patient with Post-Traumatic Stress Disorder Essay

Comprehensive Psychiatric Evaluation of a 27 Year-Old War Veteran (Sergeant Berry Sullivan) with Post-Traumatic Stress Disorder (PTSD)

Subjective:

CC: The client arrives at the treatment center alone and states that his girlfriend insisted he comes for treatment. They had gone out to a fair and sudden cracking of fireworks sent him scampering for safety. He states that he is easily startled, experiencing nightmares about the battlefield every day, hating the smell of diesel “like that of a chopper,” recalling the smell of burning human flesh when a family member singed their hair, being afraid of being stuck in a traffic jam and imagining someone throwing an IED under the car. He is also afraid of going out to public places such as malls or restaurants. As a result, he likes to spend most of his time indoors Comprehensive Psychiatric Evaluation Of a Patient with Post-Traumatic Stress Disorder Essay.

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HPI: The client is a 27-year-old Caucasian male who served in the military as a sergeant. He claims to have suffered the aforementioned symptoms since returning from service. He observed the onset of the problems as soon as he returned from the battle. His thoughts are the source of his symptoms. The complaints are ongoing, since he claims to be afraid all of the time. All he wants to do is stay inside. They are persistent and repeated, as is typical. They are exacerbated by being in the presence of a large crowd or by being stuck in traffic. When he is alone in the room all day, the symptoms subside considerably. He notices the symptoms any time day and night; but the nightmares come at night in the form of dreams every day. He believes the severity of his symptoms is at 8/10 on a scale.

Past Psychiatric History:

  • General Statement: He served in the military and was sent to war severally. He is still traumatized by what he saw and heard. For instance, improvised explosive devices or IEDs exploding and killing his colleagues.
  • Caregivers: He seems not to need any caregivers at the moment because he is not dysfunctional for self yet.
  • Hospitalizations: He has never been hospitalized for psychiatric reasons or otherwise.
  • Medication trials: He has never been put on any psychiatric treatment or medications.
  • Psychotherapy or Previous Psychiatric Diagnosis: He has not been diagnosed with mental illness before this visit. For that reason, he has also never been on any form of psychotherapy.

Substance Current Use and History: He denies smoking or using any banned substances. He drinks only occasionally at home since he is afraid of crowded places.

Family Psychiatric/Substance Use History: He has no significant family history of substance use or mental illness.

Psychosocial History: The sergeant is engaged but has no children yet. They share a home with the girlfriend with whom he is about to get married and her mother. He avoids going out because he is terrified of crowds. His girlfriend, on the other hand, occasionally takes him out, such as to the carnival. They stay in a good neighborhood with all the amenities required. There are smoke detectors in the house. He uses a seatbelt all the time when riding in a care and also does not use his phone when driving Comprehensive Psychiatric Evaluation Of a Patient with Post-Traumatic Stress Disorder Essay.

Medical History:

  • Current Medications: He not on any drugs or medications presently.
  • Allergies: He has no known allergies.
  • Reproductive Hx: He describes himself as a heterosexual male but does not have any children yet

ROS:

  • GENERAL: Denies fatigue, weakness, chills, fever, and weight loss.
  • HEENT: Negative for photophobia, otorrhea, tinnitus, rhinorrhea or a sore throat.
  • SKIN: Denies rashes, itching, or eczema.
  • CARDIOVASCULAR: Negative for chest discomfort and/ or edema of the extremities.
  • RESPIRATORY: Negative for shortness of breath, coughing, or producing sputum.
  • GASTROINTESTINAL: Denies nausea, vomiting, or diarrhea.
  • GENITOURINARY: Denies frequency, hesitancy, or painful micturition.
  • NEUROLOGICAL: Denies numbness, dizziness, syncope, or paraesthesia.
  • HEMATOLOGIC: Denies a family history of blood or clotting disorders.
  • LYMPHATICS: Negative for lymphadenopathy and splenectomy.
  • ENDOCRINOLOGIC: Negative for excessive thirst, excessive drinking of alcohol, excessive sweatness, previous hormonal therapy, and heat/ cold intolerance.

Objective:

Physical exam:

Vital signs: T- 98.8 P- 86 R 18 B/P 122/7 Ht 5’8 Wt 160lbs

Diagnostic Results and Laboratory Tests: Laboratory tests and radiological examination reveal no physical illness. The Hamilton Anxiety Rating Scale (HAM-A) performed revealed a score of 29. This is severe anxiety.

Assessment:

Mental Status Examination (MSE)

The client is a 27-year-old military vet who is aware of person, location, space, and incident. His discourse is clear, concise, and purposeful. His clothing is suitable for the time of day and climate. He appears to be in mental distress, and his self-reported mood is “anxious.” The affect is dysphoric and in sync with the above mood. There are no discernible tics, idiosyncrasies, or gestures. He is free of hallucinations and delusions. He also shows no suicidal or homicidal tendencies. Insight and judgment are still unaffected. The diagnosis made is Post-Traumatic Stress Disorder or PTSD (APA, 2013; Sadock et al., 2015).

Differential Diagnoses

Post-traumatic Stress Disorder (PTSD): Given the patient’s symptoms and his background as a war veteran, this is the most appropriate diagnosis. Being confronted by death or a threat of death or serious injury, having memories, nightmares, or flashbacks of past traumatic experiences, continuously attempting to avoid any sensory inputs related to the trauma, negative cognitive changes, changes in reactions such as hypervigilance and an exaggerated startle reflex, impairment in social and other functions, symptoms not attributable to drug use or a medical condition, and the above symptoms lasting more than one month (APA, 2013; Sadock et al., 2015).

Major Depressive Disorder or MDD: A traumatic incident is usually followed by major depressive disorder, or MDD. It is defined by DSM-5 diagnostic criteria such as persistent depression, feeling inadequate, self-blame, contemplation of death and dying, and social exclusion, among others (APA, 2013; Sadock et al., 2015). However, this diagnosis is improbable to be the primary one because MDD does not include category B and C characteristics like PTSD. Those are, intrusive and uncomfortable memories of traumatic events in the past, as well as aversion of stimuli linked with such events (APA, 2013; Sadock et al., 2015).

Psychotic Disorder: Psychotic disorders are characterized by hallucinations and illusions that might be difficult to distinguish from flashbacks at times. These perceptual distortions are a feature of DSM-5 diagnostic criteria for disorders such as schizophrenia. However, it differs from PTSD in that there has been no previous experience of a traumatic event (APA, 2013; Sadock et al., 2015).

Reflection

This full psychiatric assessment was carried out by myself utilizing evidence-based procedures for background collection and physical assessment (Ball et al., 2019; Bickley, 2017). As a result, if given the opportunity again, I would proceed in the same manner. Ethical considerations included obtaining informed consent from the patient through autonomy (Haswell, 2019). Also, I ensured that the other ethical principles of nonmaleficence (to do no harm), beneficence, and justice were respected. In terms of health education, I advised the patient to complete all CBT appointments and take part in group therapy to benefit from group therapeutic elements such as altruism, instillation of hope, interpersonal learning, self understanding, universality, group cohesiveness, catharsis, and imitative behavior amongst others (Hauber et al., 2019). I also encouraged him to begin participating in things such as athletics or other such pastimes so that he does not have time to reflect on the past traumatic experiences Comprehensive Psychiatric Evaluation Of a Patient with Post-Traumatic Stress Disorder Essay. 

References

American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Hauber, K., Boon, A.E., & Vermeiren, R. (2019). Therapeutic factors that promote recovery in high-risk adolescents intensive group psychotherapeutic MBT programme. Child and Adolescent Psychiatry and Mental Health, 13(1), 1-10. https://doi.org/10.1186/s13034-019-0263-6

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.

Training Title 21(2016). [Video/DVD] Symptom Media. https://video.alexanderstreet.com/watch/training-title-21

4 Anxiety Disorders, PTSD, and OCD

 

Your own experiences might tell you that expectations from family, friends, and work—as well as your own expectations regarding achievement, success, and happiness—can create stress. Stressors are a normal part of life, and stress traditionally has been viewed as an adaptive function with a set of physiological responses to a stressor. In a situation where stress is perceived, the organism is physiologically prepared to attack or flee from the threat. Those with effective fight or flight responses tended to survive long enough to reproduce, so we are descended from those who are genetically hardwired for self-protection. When you experience stress, your biology, emotions, social support, motivation, environment, attitude, immune function, and wellness all feel the ripple effect.

This stress response is an adaptive response the human body has to threats; however, stress can also be difficult to handle and—depending upon the nature and intensity of the stress—can result in anxiety disorders, obsessive-compulsive disorders, or trauma- and stressor-related disorders. This week, you will focus on these disorders and explore strategies to accurately assess and diagnose them.

Learning Objectives

Students will:

  • Apply concepts, theories, and principles related to patient interviewing, diagnostic reasoning, and recording patient information
  • Formulate differential diagnoses using DSM-5-TR criteria for patients with anxiety disorders, PTSD, and OCD across the lifespan

Learning Resources

 

Please watch these videos:

Please view the 2 videos to help with the documentation of the assessment. Thanks.

  1. OCD and Anxiety Disorders: Crash Course Psychology #29 https://youtu.be/aX7jnVXXG5o

 

  1. The psychology of post-traumatic stress disorder – Joelle Rabow Maletis https://youtu.be/b_n9qegR7C4

 

Required Readings (click to expand/reduce)

 

American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders

American Psychiatric Association. (2022). Obsessive compulsive and related disorders In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x06_Obsessive_Compulsive_and_Related_Disorders

American Psychiatric Association. (2022). Trauma- and stressor-related disorders… In Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders Comprehensive Psychiatric Evaluation Of a Patient with Post-Traumatic Stress Disorder Essay

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Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

  • Chapter 9, Anxiety Disorders
  • Chapter 10, Obsessive-Compulsive and Related Disorders
  • Chapter 11, Trauma- and Stressor-Related Disorders
  • Chapter 31.11 Trauma-Stressor Related Disorders in Children
  • Chapter 31.13 Anxiety Disorders in Infancy, Childhood, and Adolescence
  • Chapter 31.14 Obsessive-Compulsive Disorder in Childhood and Adolescence

Document: Comprehensive Psychiatric Evaluation Template

Document: Comprehensive Psychiatric Evaluation Exemplar

 

Required Media (click to expand/reduce)

 

Classroom Productions. (Producer). (2015). Anxiety disorders [Video]. Walden University.

 

Classroom Productions. (Producer). (2012). The neurobiology of anxiety [Video]. Walden University.

 

Classroom Productions. (Producer). (2015). Obsessive-compulsive disorders [Video]. Walden University.

 

Classroom Productions. (Producer). (2015). Trauma, PTSD, and Trauma-Informed Care [Video]. Walden University.

MedEasy. (2017). Anxiety, OCD, PTSD and related psychiatric disorders | USMLE & COMLEX [Video]. YouTube. https://www.youtube.com/watch?v=-BwzQF9DTlY

Video Case Selections for Assignment (click to expand/reduce)

Select one of the following videos to use for your Assignment this week. Then, access the document “Case History Reports” and review the additional data about the patient in the specific video number you selected.

Symptom Media. (Producer). (2017). Training title 15 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-15

Symptom Media. (Producer). (2016). Training title 21 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-21

Symptom Media. (Producer). (2016). Training title 37 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-37

Symptom Media. (Producer). (2016). Training title 40 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-40

Symptom Media. (Producer). (2017). Training title 55 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-55

Symptom Media. (Producer). (2017). Training title 85 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-85

Symptom Media. (Producer). (2018). Training title 95 [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-95

Document: Case History Reports

4 Anxiety, PTSD, and OCD

Posted on: Monday, June 20, 2022, 8:00:00 AM EDT

Hello Everyone,

I hope you all are having a great week. This week focuses on anxiety, PTSD, and OCD. I thought you find the videos below helpful:

If you have questions as always, please ask.

Dr. Perrigo

Name: Sergeant Berry Sullivan
Gender: male Age:27 years old T- 98.8 P- 86 R 18 B/P 122/7 Ht 5’8 Wt 160lbs
Background: He entered the military just after high school and did three long tours of duty in warzones. He separated from active duty in the Marines (MOS 0800 Field Artillery) six months ago after eight years of service. He is engaged to be married in 8 months and is using his GI Education Bill to attend an online college for accounting. He said he grew up poor and would not do much else if he didn’t go into the military. He denies ever using any drugs and avoids alcohol because his father was “abusive when he was drunk.”
Father is still alive, unwell (DM, cirrhosis, HTN), and still drinking. Paternal grandfather was also a veteran and suffered depression at times though he never told anyone except the patient because of their combat connection. He has one younger brother and one older sister. He lives in a different state, approximately five hours from his parents and siblings.
After the military, he and his fiancé moved because she got a much better opportunity. They want kids someday. Has service-connected asthma, seasonal allergies; no hx of psychiatric or substance use treatment. Symptom Media. (Producer). (2016).

Training title 21 [Video]. https://video-alexanderstreetcom.ezp.waldenulibrary.org/watch/training-title-21

Please Click on Direct Link to complete case you must log in to Walden Website to view the complete viewing of this case (session is 12 minutes long): Training Title 21 – Alexander Street, a ProQuest Company (openathens.net) Comprehensive Psychiatric Evaluation Of a Patient with Post-Traumatic Stress Disorder Essay