Post-Traumatic Stress Disorder Essay: Assessing and Diagnosing A Patient with Post-Traumatic Stress Disorder (PTSD) Based on Training Title 18
Subjective Assessing and Diagnosing Post-Traumatic Stress Disorder Essay:
CC (chief complaint): A.D. is a twenty-year-old female military officer present for post-traumatic stress disorder (PTSD). She is in therapy upon the recommendation of her boyfriend L, who she lives with off-base. She said that other people in her life think that she has PTSD due to her military service.
HPI: The client, A.D., is a twenty-year-old female army officer currently serving MOS 92M Mortuary Affairs Specialist, present for post-traumatic stress disorder (PTSD). She has been on anti-depressants throughout her childhood and teenage years but had to quit before enlisting in the military. Upon quitting the medication, she was depressed, which was worsened by her military service in Iraq. The PTSD manifests in a deep sense of guilt, and the client also has suicidal thoughts. She, however, has no nightmares. Other people in her life suggested that she gets therapy.
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Past Psychiatric History Post-Traumatic Stress Disorder Essay:
- General Statement: The patient was in treatment for her depression until she was at the age of eighteen years, a period that she has been on anti-depressants. She is, however, being treated for PTSD for the first time.
- Caregivers (if applicable): She has no caregivers since she can take care of her personal and professional needs.
- Hospitalizations: She has never been hospitalized
- Medication trials: The client has never been treated for PTSD but was on anti-depressants until eighteen.
- Psychotherapy or Previous Psychiatric Diagnosis: The patient reports on the various indications suggesting she may be having PTSD, for example, her sense of guilt. She is expressive of the multiple aspects of her life and how PTSD may have affected her. The PTSD has affected her everyday activities but has not caused nightmares.
Substance Current Use and History: The patient has been on anti-depressants until she was eighteen years old when she joined the army.
Family Psychiatric/Substance Use History: Her brother has a history of cannabis use.
Psychosocial History: The patient serves as a MOS 92M Mortuary Affairs Specialist in the army. She lives with her boyfriend L. off the military base. The PTSD affects her romantic relationship through her sense of guilt and the reportedly lost sex drive. The patient is avoidant of all social activities and prefers keeping to herself.
Post-Traumatic Stress Disorder Essay Medical History:
- Current Medications: The patient had been on anti-depressants until she was the age of eighteen years. She is currently not on medication.
- Allergies: The client has no known allergies.
- Reproductive Hx: Her menstrual cycle affects her PTSD and depression, whereby the symptoms are more intense during her menstrual cycles.
ROS Post-Traumatic Stress Disorder Essay:
- GENERAL: The patient has lost her sex drive, associated with post-traumatic stress disorder. No weight loss, fatigue, weakness, chill, or fever were reported.
- HEENT: Throughout, nose, ears; no hearing loss, sore thought, running nose, congestion, or sneezing reported. Eyes: no yellow sclerae, double vision, blurred vision, or vision loss.
- SKIN: No rash or itching reported
- CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
- RESPIRATORY: No shortness of breath, cough, or sputum.
- GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhoea. No abdominal pain or blood.
- GENITOURINARY: Burning on urination, urgency, hesitancy, odour, odd colour.
- NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
- MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
- HEMATOLOGIC: No anaemia, bleeding, or bruising.
- LYMPHATICS: No enlarged nodes. No history of splenectomy.
- ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Objective Assessing and Diagnosing Post-Traumatic Stress Disorder Essay:
Physical exam: Not applicable
Diagnostic results:
- Depression disorder
The patient reports experiencing depression in her teenage and childhood. Additionally, other people in her life suggest that she gets treatment for PTSD. The patient shows self-awareness of her history of depression that has affected her health and interaction with other people. Additionally, the patient was on anti-depressants which she no longer takes since joining the military.
Assessing and Diagnosing Post-Traumatic Stress Disorder Essay:
Mental Status Examination: A.D is an African American female aged twenty years old. She depicts well-groomed in her military uniform at the time of the interview. Additionally, she is self-aware in her analysis of her mental health problem’s impact on other aspects of her life. She does not report any negative impact of PTSD on her physical health. There’s no evidence of drug abuse in the attempt to mitigate her health problems. Additionally, the patient does not depict any evidence of delusion thinking. However, she reports having suicidal thoughts due to her depression and PTSD.
Differential Diagnoses Post-Traumatic Stress Disorder Essay:
- Passive suicidal ideations
This is the stream obsession with committing suicide and the desire to be no longer alive. Like the case of A.D., she reports social withdrawal and the desire to isolate herself from her films. She often feels helpless upon slightly disappointing news where she spends a lot of time crying. She reports that she believes that God has stopped her from committing suicide.
- Depression
Depression is a mood disorder whereby the patient reports anger, loss and sadness. A.D. shows signs of self-loathing through the therapy session, where she relays the numerous ways her life is affected by her mental health. Additionally, she has been treated for depression with the use of anti-depressants (Kaimal et al., 2018). The depression has, however, not affected other aspects of her life.
- Post-traumatic Stress Disorder
PTSD is a mental health condition whereby the patient experiences severe anxiety, nightmares, and flashback to a terrifying event they witnessed or participated in in the past. Working as a MOS 92M Mortuary Affairs Specialist for the United States Army, A.D. is still disturbed by the condition of the bodies she was dealing with (Wallace & Sweetman, 2020). This would be the primary diagnosis; however, it would be important to attend to her predisposition to depression.
Assessing and Diagnosing Post-Traumatic Stress Disorder Essay Reflections:
After a comprehensive psychiatric evaluation, it is evident that the patient could be suffering from both depression and post-traumatic stress disorder. Additionally, people who have observed them over long periods suggest that she has PTSD. This indicates that they have observed a change in her behaviour over a long period.
However, she was on anti-depressants before joining the military. However, the PTSD from her work in Iraq could have worsened her mental health. It would be important that she be treated for both depression and PTSD. The fact that she has continued to work indicates that her condition is moderately severe. Her support system is expected in playing a critical role in her recovery.
