Assessment and Diagnosis of Patients with Anxiety Disorders, PTSD, and OCD – Sample Assignment

Assessment and Diagnosis of Patients with Anxiety Disorders, PTSD, and OCD – Sample Assignment

Subjective:

Chief Complaint (CC): The individual struggles with negative situations.

History of Present Illness (HPI): Mr. Sullivan, a 27-year-old man, sought a mental examination after serving in the military for eight years and deciding to leave active service in the marines. He joined the military right after high school and completed three extended tours in various warzones. Given his prolonged exposure to different warzones, it is likely that he experienced traumatic events during his military service. He also mentioned that his father becomes abusive when drunk, which has deterred him from using alcohol or drugs. Mr. Sullivan denies experiencing any symptoms of anxiety, PTSD, or major depressive disorder.

Past Psychiatric History:
– Mr. Sullivan, 27, was raised in a low-income family with an alcoholic father who displayed abusive behavior when drunk. He enlisted in the military right after high school and left the service less than a year ago. He now seeks psychiatric evaluation for anxiety, PTSD, and major depressive disorder. He reports that his paternal grandfather, who also served in the military, had depression but never disclosed it.
– Caregivers (if applicable): Not applicable
– Hospitalizations: Mr. Sullivan has no prior history of psychiatric treatment or substance abuse therapy. (Further inquiry is needed regarding any psychiatric treatment, inpatient mental hospitalization, or intensive outpatient treatment during his military service or in the past).
– Medication trials: Unknown
– Psychotherapy or Previous Psychiatric Diagnosis: Unknown

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

Family Psychiatric/Substance Use History:
– Sullivan’s father is a heavy drinker who becomes abusive when intoxicated.
– The client’s paternal grandfather, who served in the military, had depression.

Psychosocial History: Mr. Sullivan was born into a low-income family with an alcoholic and abusive father. His father currently has various health conditions, including DM, liver cirrhosis, and HTN. His mother is in good health. He has two siblings, one brother, and one older sister. The family also includes his paternal grandfather, who had depression. Mr. Sullivan served in the military for eight years and now lives with his fiancée.

Medical History:

Current Medications: Mr. Sullivan is currently taking asthma medication, which is related to seasonal allergies from his military service.

Allergies: None

Reproductive History: Mr. Sullivan has no children but desires to have them someday.

Review of Systems (ROS):
– GENERAL: Mr. Sullivan appears attentive, oriented, well-groomed, appropriately dressed for the weather and occasion, and not in severe discomfort.
– HEENT: No signs of trauma or head injury.
– SKIN: No skin rash or pruritus reported.
– CARDIOVASCULAR: Mr. Sullivan denies chest pain, discomfort, congestion, and lower extremity edema.
– RESPIRATORY: Mr. Sullivan reports difficulty catching his breath.
– GASTROINTESTINAL: Mr. Sullivan experiences nausea and vomiting.
– GENITOURINARY: No abnormal urine color or dysuria reported.
– NEUROLOGICAL: No symptoms of neurological conditions.
– MUSCULOSKELETAL: No joint pain, swelling, or muscle pain.
– HEMATOLOGIC: No bleeding, bruising, or signs of blood infection.
– LYMPHATICS: No enlarged lymph nodes.
– ENDOCRINOLOGIC: No polyuria, polydipsia, or polyphagia.

Objective:

Physical Examination:
– Temperature: 98.8°F
– Pulse: 86 beats per minute
– Respiratory Rate: 18 breaths per minute
– Blood Pressure: 122/70 mm Hg
– Height: 5 feet 8 inches
– Weight: 160 pounds

Diagnostic Results: The healthcare provider should assess the individual for depression and anxiety scores. Additionally, a blood test should be requested to determine the complete blood count and thyroid-stimulating hormone levels.

Assessment:

Mental Status Examination:
– Appearance: The individual is well-groomed. Providers should check for any odors.
– Eye Contact: Fair
– Speech: Everyday speech with normal rhythm and volume.
– Behavior: Cooperative and calm.
– Psychomotor: No involuntary movements.
– Mood: Depressed.
– Thought: Paranoid, organized, goal-directed.
– Thought Content: No delusions. The provider should inquire if the individual has thoughts of self-harm or suicidal ideation.
– Perception: No reaction to external stimuli; further assessment for signs like audio-visual hallucinations is needed.
– Concentration: Demonstrates sustained attention and concentration.
– Cognition: Alert
– Memory: Demonstrates recollection of events, suggesting both short-term and long-term memory may be compromised.
– Insight: Fair
– Judgment: Fair
– Fund of Knowledge: Moderate
– Intelligence: Average

Differential Diagnoses:

1. Post-Traumatic Stress Disorder (PTSD):
PTSD is a mental disorder often seen in individuals who have experienced or witnessed traumatic events such as natural disasters, terrorism, or serious accidents. Symptoms include memory impairment related to trauma, low self-esteem, pathological guilt, negative emotions, reduced engagement in activities, detachment, and emotional numbing. Other symptoms may include irritability, aggression, sleep disturbances, and impaired concentration. PTSD should be considered as the primary mental health issue due to symptom alignment.

2. Anxiety Disorder:
Anxiety disorders are characterized by excessive anxiety, leading to difficulties in daily life. Symptoms may include nervousness, palpitations, sweating, shortness of breath, trembling, chest pain, nausea, dizziness, fear of death or insanity, and paresthesias.

3. Major Depressive Disorder:
Major depressive disorder is characterized by persistent feelings of sadness and loss of interest, affecting emotions, thoughts, and behavior. Common symptoms include a depressed mood, loss of interest in previously enjoyed activities, and various emotional and physical difficulties.

Reflections:

Mr. Sullivan’s case highlights the significant trauma experienced by military personnel during and after their service, often leading to mental health challenges like anxiety, depression, and PTSD. These challenges may remain hidden due to stigmatization and perceptions of weakness. It is crucial to support veterans and encourage them to seek help. Proper education and training can help recognize signs and symptoms of mental conditions, and timely resources and services should be provided to eliminate barriers to mental health treatment.

References:

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

2. 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.

3. Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (201

9). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in context, 8.

4. 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.

5. 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.