Psychiatric Evaluation Assignment Discussion Paper

Subjective:

CC (chief complaint): “My fiancé suggested, well demanded that I make an appointment”.

HPI:

PF is a 27-year-old Caucasian man who presents for clinical examination because he is experiencing symptoms of post-traumatic stress disorder. At the moment, he is not using any medicine, and his fiancée has advised him to be assessed. A little more than a year ago, he completed his service in the Marines after eight years. Following an incident that occurred three days before, the patient’s fiancé insisted on his being assessed. They were visiting a carnival when fireworks were off suddenly. This elicited a response from the patient, who immediately started fleeing in search of protection.  He said that it left him feeling really scared. The two officers continued chasing after him as he was sprinting away, and they eventually brought him to the ground, where they attempted handcuffing him. Because they were both war veterans, they stepped back when the patient said he was a combat veteran. His mind was whisked back in time to the battleground as the explosions seemed like fighting fire. Noisy sounds, such as a vehicle going to backfire or a loud circular saw, are among his triggers. A BBQ was taking place when his companion accidentally burnt some hair on his arm, causing him to leave the event soon after being alerted by the smell. He tells, with much trouble, that two of his buddies were killed and two others were hurt when their Humvee was blown up. He claims that he has horrible nightmares, which makes it difficult for him to go asleep since he doesn’t want to shut his eyes. Aside from that, he admits to being easily frightened. Traffic appears to be a source of his memories and anxiety Psychiatric Evaluation Assignment Discussion Paper.

ORDER YOUR PAPER HERE

Past Psychiatric History

  • General Statement: The client has never been seen by a mental health professional in his whole life. This is the first time he’s been to the doctor about his concerns.
  • Caregivers: His Fiancé
  • Hospitalizations: None
  • Medication trials: Not

According to American Psychiatric Association (2015), medication trials are required because they provide the opportunity to reevaluate the correctness of the diagnosis and to possibly prevent the administration of medicines that did not work or produced adverse effects in the patient Psychiatric Evaluation Assignment Discussion Paper.

  • Psychotherapy or Previous Psychiatric Diagnosis: The client has never discussed his present condition with anybody else and has never been diagnosed with a mental disorder.
  • Substance Current Use and History: Denies tobacco, alcohol, and illicit drug use.

Family Psychiatric/Substance Use History:  Paternal Grandfather served in the military and suffered from depression, but was never diagnosed. Father is an alcoholic

Psychosocial History:

The patient’s father and mother raised him. He has two sisters, one who is older and one who is younger than he is. He and his fiancée presently live in a house without children, but they would like to have children in the future. In addition, they want to tie the knot within the next two years, if everything goes as expected. His greatest degree of education is that of a high school graduate. He is presently employed as a furniture sales representative. There is no record of his legal history. Trauma comprises situations that occurred when he was serving abroad as an adult.

Medical History:

No known medical history.

This section of the psychiatric assessment could be used to kick off the interview by asking questions regarding symptoms and the client’s history based on the information obtained (American Psychiatric Association, 2015).

  • Current Medications: Not provided

Because of the possibility of drug interactions, it is essential to know about any other drugs that the client is taking.

  • Allergies: Seasonal
  • Reproductive Hx: Not provided

 

ROS:

GENERAL: Denies fatigue, weakness, chills, fever, and weight changes.

HEENT: Eyes: Denies yellow sclerae, double vision, blurred vision, and visual loss. Ears, Nose, Throat: Denies hearing loss, runny nose, congestion, sneezing, or and throat soreness.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest discomfort, pressure, and pain. Denies edema and palpitations.

RESPIRATORY: Denies cough, breathing problems, sputum, and phlegm.

GASTROINTESTINAL: Denies abdominal pain, diarrhea, vomiting, nausea, and anorexia.

GENITOURINARY: Denies odd color, odor, hesitancy, urgency, and burning on urination.

NEUROLOGICAL: Denies headaches, ataxia, paralysis, syncope, dizziness, tingling and numbness in           the extremities.

MUSCULOSKELETAL: Denies joint pain and stiffness. Denies back pain, and muscle, pain.

HEMATOLOGIC: Denies bleeding, easy bruising, and anemia.

LYMPHATICS: Denies having any enlarged nodes. Denies history of splenectomy.

ENDOCRINOLOGIC: Denies polydipsia and polyuria. Denies sweating, heat and cold intolerance Psychiatric Evaluation Assignment Discussion Paper.

Objective:

Physical exam:

  • Vitals: T- 4, P- 84, R 18, B/P134/88, Height: 5’8, Weight: 167lbs
  • General: Alert and oriented x4, in no apparent distress. Mood and appearance are appropriate.
  • Lungs: Symmetrical chest. Breath sounds clear and equal in all lung
  • Heart: S1 and S2 No adventitious sounds heard.

Diagnostic results:

  • Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)

This is a typical diagnostic test that is used to detect post-traumatic stress disorder. It consists of 30 questions that are used to evaluate the duration of symptoms, analyze symptoms, the effect of symptomatology on interactions and activities, the intensity of symptoms, and the existence of dissociative clinical features in a person (Polizzi, 2021)Psychiatric Evaluation Assignment Discussion Paper.

Assessment:

Mental Status Examination:

  • PF is a 27-year-old Caucasian man who seems to be his given age. He is alert, oriented, and capable of communicating his concerns. During the interview, he exhibits signs of nervousness while still being cooperative. He is well attired and well groomed for the occasion. There is no indication of aberrant motor activity. He has clear and coherent speech and of a standard volume and tone.  He has goal focused and rational thought processes. During the interview, he looks to be apprehensive, and his affect is fitting for his state of mind. He has good insight and concentration. His short- and long-term memory are both fully intact. Neither auditory nor visual hallucinations were reported by the client. As for whether he had suicide or homicidal thoughts, he did not talk about it Psychiatric Evaluation Assignment Discussion Paper.

Differential Diagnoses:

  1. PTSD: One of the most prevalent diagnoses for soldiers with PTSD is post-traumatic stress disorder (PTSD). In the Diagnostic and Statistical Manual of Mental Disorders, Version V, there are eight diagnostic criteria for PTSD. An imminent or real death or other horrific events, as well as other significant occurrences, must have occurred in order for an individual to be classified with PTSD (Hamblen et al., 2019). There are many ways to be directly influenced by an occurrence, including being an observer to the occurrence, finding about the incident from someone close to the individual, and being exposed to traumatic occurrences. When a combatant or a law enforcement officer is exposed to the same occurrences over and over again, they are said to be exposed to repeated exposure. There must be at least one of the following indications existing:  recurrent, unpleasant, and disturbing thoughts about the incident, as well as flashbacks and nightmares to the incident itself. Sources of stress may be internal or external, like loud sounds or big crowds, and they can cause mental anguish as well as significant physical responses (Hamblen et al., 2019). A person’s life must be significantly disrupted for at least a month, and the disruption cannot be induced by a substance such as alcohol, medicine, or another health problem Psychiatric Evaluation Assignment Discussion Paper.
  2. Acute Stress Disorder: This illness exhibits symptoms that are comparable to those of post-traumatic stress disorder (PTSD), as well as functioning issues after a stressful experience. Following a thirty-day observation period, the diagnosis is re-evaluated and altered to post-traumatic stress disorder (Hamblen et al., 2019). The presence of severe disabling symptoms is required for a diagnosis of acute stress disorder to be made. They should also make a concerted attempt to prevent situations that might set off the occurrence (Bryant, 2021).
  3. Panic Disorder: In accordance with the DSM-V diagnostic criteria, an individual suffering from a panic attack has to be apprehensive about experiencing another incident for a minimum of one month after the previous episode (Cosci & Mansueto, 2019). Moreover, they ought to be concerned about the repercussions or avoid situations that might provoke them. It is possible that the panic attacks are not caused only by the usage of illicit drugs or by another medical problem. The physical symptoms that individuals face during a panic attack include palpitations, rapid breathing, and perspiration.

Reflections: In examining this case and the DSM-V criteria, I was able to get a better understanding of post-traumatic stress disorder (PTSD). It was also revealed to me that acute stress disorder was a kind of pre-PTSD diagnosis. According to me, the most important thing to do differently is to inquire about drug trials and present drugs. This is critical for any assessment, as well as for any physician who will be recommending drugs and other therapies to their patients Psychiatric Evaluation Assignment Discussion Paper.

ORDER YOUR PAPER HERE

References

American Psychiatric Association. (2015). The american psychiatric association practice guidelines for the psychiatric evaluation of adults (3rd ed.). https://doi.org/10.1176/appi.books.9780890426760.pe02

Bryant. (2021). Acute stress disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis. UpToDate.

Cosci, F., & Mansueto, G. (2019). Biological and clinical markers in panic disorder. Psychiatry Investigation, 16(1), 27-36. https://doi.org/10.30773/pi.2018.07.26

Hamblen, J. L., Norman, S. B., Sonis, J. H., Phelps, A. J., Bisson, J. I., Nunes, V. D., … & Schnurr, P. P. (2019). A guide to guidelines for the treatment of posttraumatic stress disorder in adults: An update. Psychotherapy, 56(3), 359. Psychiatric Evaluation Assignment Discussion Paper https://psycnet.apa.org/record/2019-36160-004

Polizzi. (2021). Ptsd diagnosis: Tests, screening, and criteria. Verywell Health. https://www.verywellhealth.com/how-ptsd-is-diagnosed-5114706

PTSD case study

Training Title 21

Name: Sergeant Patrick Flanrey Gender: male Age:27 years old T- 97.4 P- 84 R 18 B/P134/88 Ht 5’8 Wt 167lbs 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) less than a year ago after eight years of service. He is engaged to be married (no date set) and is currently working as a furniture salesman. 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 “sloppy drunk.” Father is still alive, unwell (DM, liver disease, HTN), 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. Mother is alive and well, still “caring for dad.” He has one younger 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 and hope to marry in a year or two. Has service-connected asthma, seasonal allergies; no hx of psychiatric or substance use treatment. Symptom Media. (Producer). (2016).

ORDER  HERE

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

Psychiatric Evaluation Assignment Discussion Paper