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

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Week 4: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD

College of Nursing-PMHNP, Walden University

NRNP-6635-15-Psychpathology Diagnoses Reasoning

Subjective:

CC (chief complaint): Loud noice frigthenes me and makes me panic.

HPI: P.F is a 27 years old male with history of service asthma, and no psychiatric history came in due to his fiancé concern about his behavior and episode he encountered at county fair three nights ago.  He heard a fire works and he started running to take cover because he was frightened.  He joined military just after high school and did three long tours of duty in warzones.  He served for 8 years in the Marine until less than a year ago. He mentioned how loud noices, too many traffics, and burning smells triggers his combat memories in overseas. No weakness, fever, or chills noted.

Past Psychiatric History:

  • General Statement: Patient seek for treatment due to his recent encounter he had at County Fair during fireworks.
  • Caregivers (if applicable): None
  • Hospitalizations: None
  • Medication trials: None
  • Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: No Alcohol or drug use

Family Psychiatric/Substance Use History: Father is still alive and unwell, and he is an alcoholic with a medical histories of DM, liver disease, HTN . Paternal grandfather was a veteran and also suffers depression.

Psychosocial History:  Patient was raised by his parents and he has one older sister and one younger brother. He grew up in a poor family and he moved with his fiancé to another state for a better opportunity. The plan to get married someday and have their children.  He currently works at furminture store as a salesman. He joined Marine after his high school.

Medical History:  Service asthma only.

 

  • Current Medications: None
  • Allergies: Seasonal allergies
  • Reproductive Hx: None

ROS:

  • GENERAL: No weight gain, No fever or chills. Denies weakness or fatigue.
  • HEENT: Denies head trauma or head injuries, No vision discomfort, No ear pain, or discharges. No rhinorrhea, sore throat or difficulty swallowing. Denies
  • SKIN: No rashes or redness.
  • CARDIOVASCULAR: Denies chest pain, or peripheral edema. Palpitation only when feeling anxious.
  • RESPIRATORY: Denies shortness of breath, or cough
  • GASTROINTESTINAL: Patient denies nausea, vomiting, constipation, diarrhea, bloating, and heart burn. No abdominal pain.
  • GENITOURINARY: Denies dysuria, requency or urgency. Denies bilateral flank pain or hematuria.
  • NEUROLOGICAL: No headache, tingling, numbness, paralysis. No bladder or bowel incontinence.
  • MUSCULOSKELETAL: Denies any fracture, back pain, or muscle stiffness
  • HEMATOLOGIC: Denies bleeding or anemia.
  • LYMPHATICS: Denies nodes enlargement.
  • ENDOCRINOLOGIC: Denies heat or cold intolerance.
  • PSYCHIATRIC: Reports anxiety when triggered, and no suicidal thoughts.

 

Objective:

Physical exam: Temp- 97.4,  P- 84,  RR 18,  B/P 134/88, Ht 5’8,  Wt 167lbs

General: Patient is alert and oriented X4.  He dressed appropriate.

HEENT: Normocephalic, Right and left PERRL, no hearing problem noted. Mucosa moist and pink, Gag reflex intact.

Cardiovascular: carotid pulse 2+, with no thrill or bruit.. Normal heart rhythm S1, S2.  No heart murmur. No bruit noted in all arteries.  No edema in all extremities.

Respiratory: Chest wall and thoracic symmetrical with no deformity. Clear lung sound.

Psychiatric: Anxiety noted.

 

Diagnostic results:

Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

Mental Status Examination:

3 Differential Diagnoses:

Reflections: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

References

Week 4: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD

College of Nursing-PMHNP, Walden University

NRNP-6635-15-Psychpathology Diagnoses Reasoning

March 28, 2021Subjective:

CC (chief complaint): Loud noise frightens me and makes me panic.

HPI: P.F is a 27 years old male with history of service asthma, and no psychiatric history came in due to his fiancé concern about his behavior and episode he encountered at county fair three nights ago.  He heard a fire works and he started running to take cover because he was frightened.  He joined military just after high school and did three long tours of duty in warzones.  He served for 8 years in the Marine until less than a year ago. He mentioned how loud noices, too many traffics, and burning smells triggers his combat memories in overseas. No weakness, fever, or chills noted.

Past Psychiatric History:

  • General Statement: Patient seek for treatment due to his recent encounter he had at County Fair during fireworks.
  • Caregivers (if applicable): None
  • Hospitalizations: None
  • Medication trials: None
  • Psychotherapy or Previous Psychiatric Diagnosis: None

Substance Current Use and History: No Alcohol or drug use

Family Psychiatric/Substance Use History: Father is still alive and unwell, and he is an alcoholic with a medical histories of DM, liver disease, HTN . Paternal grandfather was a veteran and also suffers depression.

Psychosocial History:  Patient was raised by his parents and he has one older sister and one younger brother. He grew up in a poor family and he moved with his fiancé to another state for a better opportunity. The plan to get married someday and have their children.  He currently works at furminture store as a salesman. He joined Marine after his high school.

Medical History:  Service asthma only.

 

  • Current Medications: None
  • Allergies: Seasonal allergies
  • Reproductive Hx: None

ROS:

  • GENERAL: No weight gain, No fever or chills. Denies weakness or fatigue.
  • HEENT: Denies head trauma or head injuries, No vision discomfort, No ear pain, or discharges. No rhinorrhea, sore throat or difficulty swallowing. Denies
  • SKIN: No rashes or redness.
  • CARDIOVASCULAR: Denies chest pain, or peripheral edema. Palpitation only when feeling anxious.
  • RESPIRATORY: Denies shortness of breath, or cough
  • GASTROINTESTINAL: Patient denies nausea, vomiting, constipation, diarrhea, bloating, and heart burn. No abdominal pain.
  • GENITOURINARY: Denies dysuria, requency or urgency. Denies bilateral flank pain or hematuria.
  • NEUROLOGICAL: No headache, tingling, numbness, paralysis. No bladder or bowel incontinence.
  • MUSCULOSKELETAL: Denies any fracture, back pain, or muscle stiffness
  • HEMATOLOGIC: Denies bleeding or anemia.
  • LYMPHATICS: Denies nodes enlargement.
  • ENDOCRINOLOGIC: Denies heat or cold intolerance.
  • PSYCHIATRIC: Reports anxiety when triggered, and no suicidal thoughts.

Objective:

Physical exam: Temp- 97.4,  P- 84,  RR 18,  B/P 134/88, Ht 5’8,  Wt 167lbs

General: Patient is alert and oriented X4.  He dressed appropriate.

HEENT: Normocephalic, Right and left PERRL, no hearing problem noted. Mucosa moist and pink, Gag reflex intact.

Cardiovascular: carotid pulse 2+, with no thrill or bruit.. Normal heart rhythm S1, S2.  No heart murmur. No bruit noted in all arteries.  No edema in all extremities.

Respiratory: Chest wall and thoracic symmetrical with no deformity. Clear lung sound.

Psychiatric: Anxiety noted.

 

 

Diagnostic results:

Assessment:

Mental Status Examination: The patient is a 27-year old Caucasian male. He cooperates during the session and answers questions in the right manner. He is well-dressed and neat. He has normal motor activity during the interview. During the interview, he seems anxious especially when he remembers his combat experience. He sometimes tries to remember past events and to some extent avoids narrating a past event that he considers a bad memory.

Differential Diagnoses:

Based on the patient’s history and signs and symptoms, the three differential diagnoses are post-traumatic stress disorder, acute stress disorder, and generalized anxiety disorder.

Post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is the priority differential diagnosis. PTSD is a psychiatric disorder that is common among individuals that have experienced traumatic events in life such as violence, war, rape, or personal assault. According to the American Psychiatric Association (2013),  DSM-V criteria, for patients to be diagnosed with PTSD, they must present with the four cluster symptoms avoidance symptoms, intrusion symptoms, reactive symptoms, and arousal symptoms. Intrusion symptoms are recurrent and unwanted distressing memories of the traumatic event. Avoidance symptoms refer to the attempt to avoid distressing memories, feelings, or memories of a traumatic event. Arousal symptoms include jumpiness, hypervigilance, and exaggerate startle response. Reactive symptoms are whereby individuals experience reactivity responding to the reminders of the traumatic event. The patient displays these symptoms by not wanting to talk about an event that happened during combat, memories of the smell of diesel as well as loud sounds such as fireworks which saw him got frightened and even running away.

Acute stress disorder

Acute stress disorder refers to a mental condition that manifests after a month of experiencing a traumatic event (Meiser-Stedman et al., 2017). The traumatic events might include a death threat, death, or even injury to self or others. The traumatic events cause fear, helplessness, and horror. The patient during his seven years in combat whereby he faced a death threat and even witnessed his friends’ deaths.

Generalized-anxiety disorder

Generalized anxiety disorder according to the DSM-5 is a disorder that is characterized by excessive worrying and anxiety which are difficult to control (Patriquin & Mathew, 2017). The condition results in distress that may last for more than six months. It usually manifests in adulthood taking a chronic cause and reducing a person’s quality of life. During the interview, the patient appears anxious

Reflections:

If I were to see the patient again, I would engage the patient in diaphragmatic breathing which he could use to manage and at the same time lower his anxiety levels.

I would educate the patient on the available interventions and health promotion practices that would enable him manage the symptoms early enough before developing complications. I would emphasize the need for comprehensive screening to make a correct diagnosis and subsequently start either therapy or medication based on the patient’s health needs and preferences.

Legal and ethical issues.

The patient is a veteran and it was his fiance’s opinion that he should seek medical attention. An ethical issue that would arise is his willingness to comply with the recommended interventions based on a comprehensive assessment and diagnosis. Similarly, an issue of funds would arise considering that he is out of service and would need funds for his medical needs.

The patient should return to the clinic after four weeks for follow-up and updates on any change in his health and overall well-being.

 

 

 

 

 

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Meiser‐Stedman, R., McKinnon, A., Dixon, C., Boyle, A., Smith, P., & Dalgleish, T. (2017). Acute stress disorder and the transition to posttraumatic stress disorder in children and adolescents: Prevalence, course, prognosis, diagnostic suitability, and risk markers. Depression and anxiety, 34(4), 348-355.

Patriquin, M. A., & Mathew, S. J. (2017). The neurobiological mechanisms of generalized anxiety disorder and chronic stress. Chronic Stress, 1, 2470547017703993.