NRNP 6635 Assignment: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD

Subjective:

CC (chief complaint): “I don’t want to go anywhere. I just stay in my room all day afraid to sleep. It is bad”.

HPI: P.F. is a 27 year old male who is is a combat Veteran that served in the Marines and separated from active duty less than a year ago, who has come to seek psychiatry help at the insistence of his fiancé. Patient reports that things and events that may appear mundane and ordinary to other people invoke strong memories of his war time experience and cause strong reactions that are alarming to him, as well as those around him. Patient recalls certain sights, smells and sounds make him feel he is “right back in the middle of enemy fire”

Past Psychiatric History:

General Statement: Patient reports he is afraid to sleep and the extreme reactions he has are beginning to affect his entire life.
Caregivers : Patient has a fiancé who demanded he seek Psychiatric help.
Hospitalizations: No previous Hospitalizations.
Medication trials: None
Psychotherapy or Previous Psychiatric Diagnosis: No previous history

Substance Current Use and History: Patient has no history of substance abuse.

Family Psychiatric/Substance Use History: Father has a history of Alcohol abuse and paternal Grandfather who was also a combat veteran, has a history of depression.

Psychosocial History:

Patiient is currently a furniture sales man but left active service less than a year ago, afte

r long tours of duty in war zones. He is engaged to be married (no date set) and is currently working as a furniture salesman. Patient denies drug and alcohol use, has a fiancé whom he lives with, and his parents and 2 siblings live in a different state.

Medical History:

Current Medications: None indicated but patient has service connected Asthma
Allergies: Seasonal Allergies

Reproductive Hx: N/A

ROS:

GENERAL: Anxious looking male who is well dressed for the season. No weight loss, no fever, no chills.
HEENT: No visual loss, no hearing loss, no sneezing , coughing, no complaints of sore throat.
SKIN: No rash, no itching
CARDIOVASCULA: No chest discomfort, no irregular heart beat.
RESPIRATORY: Even and unlabored except when reliving past traumas
GASTROINTESTINAL: Patient complains of occasional nausea when he is reliving war time experirnces.
GENITOURINARY: No burning on urination, no hematuria.
NEUROLOGICAL: No headache, occasional dizziness, no numbness, no paralysis
MUSCULOSKELETAL: No muscle pain, no back pain.,
HEMATOLOGIC: No bleeding, bruising
LYMPHATICS: No enlarged nodes
ENDOCRINOLOGIC: No polyuria, no polydypsia. Diaphoretic when reliving traumatic events

Objective:

Physical exam: N/A

Diagnostic results: N/A

Assessment:

Mental Status Examination: Patient is alert and oriented to person, place, time and situation, speech is clear and coherent, appropriate response to questions. Patient shows signs of anxiety, and appears desperate for answers to his extreme reactions to triggers of his war time experiences. No suicidal ideations, but patient finds it difficult to sleep and has nightmares when he manages to sleep.

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Differential Diagnoses:

Post Traumatic Stress Disorder(PTSD)

This patient is a combat Veteran and so it is easy to draw a conclusion of PTSD as a diagnosis, but specific criteria have to be met before this diagnosis can be made. This patient has experienced traumatic events that happened to him and others during his career as a combat veteran and certain triggers make him react and relive these memories.

As explained by Carlat, D. (2016), all the classic signs and symptoms experienced by PTSD patients including flashbacks, nightmares, hyperarousal, and intense distress when exposed to events that are symbolic of the original event, are evident with this patient.

Generalized Anxiety Disorder

According to DSM-5, a PTSD diagnosis requires that trauma exposure precede the onset of , or excacerbation of pertinent symptoms.During the course of the interview, this patient dispalys signs of intense anxiety, and is very worried about the intense emotions he is experiencing by these triggers.

According to Sadock, B. et al., (2015), Generalized anxiety disorder (GAD)is excessive anxiety and worry about several events or activities for most days during at least a six month period. This diagnosis would not be a first choice as this patient reacts to specific stressors that remind him only of events he was a witness to, or experienced as a combat veteran.

Major Depressive disorder

This patient’s paternal Grandfather who was a combat veteran also, suffered from depression and so a thorough evaluation needs to be made to exclude depression, or consider it as a co-existing comorbity with PTSD.

Major depressive disorder (MDD) is a debilitating disease that is characterized by depressed mood, diminished interests, impaired cognitive function and vegetative symptoms, such as disturbed sleep or appetite. (Otte, C. et al., 2016). From the clinical interview, it appears this patient lives a relatively normal life and is looking forward to a life with his fiancé and is affected solely by the traumatic events he experienced as a combat veteran.

Reflections:

Sayer, N., et al., 2021 recommendTrauma-focused psychotherapies as the most effective treatment across PTSD Clinical Practice Guidelines. Reliving these traumatic experiences in a clinical, non judgemental atmosphere is a right step towards treatment. This patient should also be encouraged to engage in leisure activities that he enjoys where there would be minimal stressors to disrupt him. Patient may also benefit from joining a group where fellow veterans suffering from PTSD like him, can be a support system

Patient has already taken the first step as suggested by his fiancé to see a psychiatrist, and seems willing to do anything to relieve his reactions. As the therapist rightly said, “talking helps your brain to heal.” If insomnia persists and the quality of his sleep continues to be affected due to nightmares, a pharmacological intervention may become necessary and should be considered.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders:DSM5.

Carlat, D. (2016). The Psychiatric Interview. Lippincott Williams & Wilkins.

Otte, C., Gold, S., Penninx, B. et al. Major depressive disorder. Nat Rev Dis Primers 2, 16065 (2016). https://doi.org/10.1038/nrdp.2016.65

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

Sayer, N. A., Bernardy, N. C., Yoder, M., Hamblen, J. L., Rosen, C. S., Ackland, P. E., … & Noorbaloochi, S. (2021). Evaluation of an implementation intervention to increase reach of evidence-based psychotherapies for PTSD in US Veterans Health Administration PTSD clinics. Administration and Policy in Mental Health and Mental Health Services Research, 48(3), 450-463.

Subjective:

CC (chief complaint): “ I Can’t even begin to describe what I am feeling, sadness, fear, I guess.”

HPI: Mr. D.J. is a nineteen-year-old male patient who came to the facility for a psychiatric visit after developing symptoms of fear and sadness after he realized that he is being activated with the Navy Reserves through a stop-loss policy. These symptoms have been there for the last one and half months. He confesses to being discontent with having to listen to gay comments while serving as a soldier since he is gay. However, he fears sharing regarding his sexuality with people since he is not sure how they would react. He fears and is scared that some would be surprised and walk away from him and never come back to his side. The patient also indicates that he fears rejection and feels like he wants to die when he thinks about it. He confesses to having suicidal thoughts before but not in recent times. The patient has had delusions related to the men he works with and hopes that he can move away from such delusions.

Past Psychiatric History:

General Statement: The patient is generally healthy but is of late sad and has fear after realizing he has been activated with the Navy Reserves
Caregivers (if applicable): The patient lives with both parents as the only child
Hospitalizations: no cases of hospitalizations recorded
Medication trials: No cases of medical trials reported
Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric history.

Substance Current Use and History: The patient has not used or is not using any substances, alcohol, or cigarette

Family Psychiatric/Substance Use History: There is no substance use or family psychiatric history.

Psychosocial History: D.J is a nineteen-year-old patient who lives with both parents in Minneapolis. The patient has no partner currently and works at Starbucks as a part-timer. The patient’s MOS is an SK1 storekeeper

Medical History:

Current Medications: The patient is currently not using any medications
Allergies: No known allergies
Reproductive Hx: The patient has no partner currently. He confirms that he is gay and has known his sexual identity since the age of eight.

ROS:

GENERAL: The patient is calm and cooperative
HEENT: The head is normal. No eye infection, double vision, double vision, or visual loss. No ear infections or hearing loss. No nose congestion or sneezing. No sore throat
SKIN: no rashes, itchiness, or irritation
CARDIOVASCULAR: No chest discomfort, pressure, or pain was reported
RESPIRATORY: NO congestion, no breathing problems
GASTROINTESTINAL: no eating disorders, no abdominal ailments
GENITOURINARY: no pain passing urine, no urge for frequent urination
NEUROLOGICAL: Reports being sad and having fear. He is also scared and anxious
MUSCULOSKELETAL: No glutes, no muscle or back pain
HEMATOLOGIC: No blood infections were reported
LYMPHATICS: No swelling was noted
ENDOCRINOLOGIC: has no abnormal sweating or excessive thirst

Objective:

Vitals: T- 98.8, P- 89, R 18 110/62 Ht 5’7 Wt 133lbs.

Physical exam: if applicable

Diagnostic results: none was conducted

Assessment:

Mental Status Examination:

D.J is a nineteen-year-old male patient who visited the clinic with the claims of fear and sadness. The patient is well-dressed and groomed. He is keen to participate in the psychiatric examination and assessment. He has normal speech with consistent volume and normal tone. The patient confirms delusional thoughts. He confirms to have had suicidal thoughts sometimes back to not anymore. The patient’s thought process is intact. His short-term and long-term memory are both intact. His mood is sad, and he feels scared to be rejected by people.

Differential Diagnoses:

Social Anxiety Disorder: This is a type of anxiety disorder known to make individuals have symptoms such as excessive self-consciousness and anxiety in a social situation. According to the DSM-5 criteria, the diagnosis of a social anxiety disorder includes fear of anxiety unexplainable through substance abuse, medication use or substance use, and distress or anxiety which impairs daily life, avoidaing of anxiety-prodocing situations (Koyuncu et al.,2019). The other symptom is intense fear or anxiety regarding a particular social situation because of fear of being humiliated, embarrassed, or negatively judged (APA, 2022). The patient has displayed all these symptoms. He fears revealing his sexuality to workmates for fear of being judged; he also seems to avoid going to active duties since it is unpleasant to him hearing people make comments regarding gays. Therefore, this is likely to be the primary diagnosis.
Generalized Anxiety disorder (GAD). This is a condition that may make an individual have extreme worry and fear about various aspects of life. A person may have a constant feeling of being overwhelmed, fearful, and excessive worry regarding various things (Sadock, 2015). The implication is that such individuals usually have problems controlling nervousness or worry (Crocq, 2022). The patient in this case study has displayed these symptoms. The patient has feelings of sadness and worry, which have been triggered by realizing that his active service is being extended. He also feels anxious and scared about revealing his sexuality to his workmates and fears that some may leave him, never to return.

Major Depressive Disorder: This is a type of depression where an individual displays intense depressive symptoms for more than a fortnight, hence interfering with normal functionality or everyday life (Mullen, 2018). The feelings may include hopelessness, being anxious, and feeling sad. According to the DSM-V criteria, an individual is diagnosed with a major depressive disorder when the individual displays symptoms such as feelings of worthlessness, low or sad most of the time for at least a fortnight, change in appetite, loss of interest in activities and sleep problems (Zimmerman et al.,2019). Even though the patient has shown symptoms such as anxiety and sadness, he sleeps well, eats well since he has a good appetite, and has not reported losing interest in activities. Therefore, this condition looks less likely, though it is considered a differential diagnosis.

Reflections:

This case study presented an opportunity to learn more about mental health conditions. This patient presented with fear and sadness resulting largely from his sexual identity. He finds it difficult to go back for active duties, which he has associated with unpleasant comments regarding being gay as he is also gay. The anxiety and fear regarding his sexual identity extend to the other workplace, where he is skeptical about telling others about his sexual identity for fear of being judged or left by others. If I was in the same position as the healthcare professional, there are various things I would have done differently. For example, I would have inquired more about his daily life and how he feels regarding his functionality. This would have led to a better insight into the physical impacts of the condition. The patient is so sensitive about his secrets being shared with other people; as such, I will endeavor to keep the information confidential (Sussman, N., & DeJong, 2018). One of the social determinants of health that is applicable in this case is social support. The patient is sad and has a fear of the extended active duty, as well as worries and fear concerning how to reveal his sexual identity. Therefore, the patient needs adequate social support to help him through the difficulties he is facing (Wang et al.,2018).

References

American Psychiatric Association. (2022). Trauma- and stressor-related disorders. In the Diagnostic and statistical manual of mental disorders

Crocq, M. A. (2022). The history of generalized anxiety disorder as a diagnostic category. Dialogues in Clinical Neuroscience. https://doi.org/10.31887/DCNS.2017.19.2/macrocq

Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs In Context, 8. https://doi.org/10.7573%2Fdic.212573

Mullen, S. (2018). Major depressive disorder in children and adolescents. Mental Health Clinician, 8(6), 275–283. https://doi.org/10.9740/mhc.2018.11.275

Sadock, B. J. (2015). Sadock’s synopsis of psychiatry: behavioral sciences. Rezaee F.(Persian translator). 11th ed. Tehran: Arjmand pub, 399-410.

Sussman, N., & DeJong, S. M. (2018). Ethical considerations for mental health clinicians working with adolescents in the digital age. Current Psychiatry Reports, 20(12), 1-8. https://doi.org/10.1007/s11920-018-0974-z

Wang, J., Mann, F., Lloyd-Evans, B., Ma, R., & Johnson, S. (2018). Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review. BMC Psychiatry, 18(1), 1–16. https://doi.org/10.1186/s12888-018-1736-5

Zimmerman, M., Martin, J., McGonigal, P., Harris, L., Kerr, S., Balling, C., … & Dalrymple, K. (2019). Validity of the DSM‐5 anxious distress specifier for major depressive disorder. Depression and Anxiety, 36(1), 31–38. https://doi.org/10.1002/da.22837

CC (chief complaint): “Sadness and fear.”

HPI: D.J is a 19-year-old male patient who came in for a psychiatric evaluation to seek answers to some questions. He reports being sad and afraid following the recent announcement that he has been activated with the Navy Reserves. The patient is currently in the U.S Navy reserves and finds it difficult to talk about his sexuality once he is back in service. He is scared of being rejected or treated differently when important people in his life found out that he is gay. He also fears that they might not approve of him. He reports suicidal thoughts due to the fear of rejection. He has been presenting with these symptoms since about two months ago when he realized that he is going to be deployed. Denies a history of suicidal attempts.

Past Psychiatric History:

General Statement: No history of any other mental disorder other than the current concerns. Reports suicidal thoughts due to the fear of rejection because of his sexuality.
Caregivers (if applicable): The patient is the only child, staying with both his parents.
Hospitalizations: Reports no history of hospitalization.
Medication trials: Denies use of any medication for the management of his psychiatric symptoms.
Psychotherapy or Previous Psychiatric Diagnosis: No history of psychiatric diagnosis or use of psychotherapy.

Substance Current Use and History: The patient denies the use of alcohol, cigarettes, or any other illicit drug of abuse.

Family Psychiatric/Substance Use History: Reports no family member having a history of any mental disorder or substance use.

Psychosocial History: The patient is an only child and lives with both his parents in Columbus, OH. He has a dog by the name of Chance. He currently works part-time on a construction site, as he is currently in U.S Navy Reserve. He sleeps adequately every night and tries to eat healthily. His current mental symptoms started two months ago when he was informed that he is being activated with the army reserves.

Medical History: No history of any other medical problem reported at the moment.

Current Medications: Denies use of any drug.
Allergies: No known drug, food, or seasonal allergies
Reproductive Hx: The patient is homosexual (gay), but currently single. Denies ever engaging in sex before. Reports no history of sexually transmitted infections.

ROS:

GENERAL: No fatigue, weight changes, chills, fever, fatigue or general weakness, or night sweats.
HEENT: Head: atraumatic. Eyes: No visual changes, blurred vision, use of corrective lenses, or red/itchy eyes. Nose: No congestion, irritations, inflammation, nose bleeding, or sinus problems. Throat & Mouth: No sore throat, bleeding gums, or swallowing difficulties.
SKIN: No rashes, hives, ulcers, blisters, or lumps. Warm, with uniform color.
CARDIOVASCULAR: No history of cyanosis or hurt murmurs. Denies chest pain or palpitations. Pulmonary: No cough, shortness of breath, wheezing, or sneezing. Denies pleuritic pain.
RESPIRATORY: Denies wheezing, shortness of breath, sputum, cough, emphysema, bronchitis, pneumonia, or history of tuberculosis.
GASTROINTESTINAL: No Tenderness, diarrhea, vomiting, abdominal pain or discomfort, bloating, jaundice, constipation, or changes in bowel movement.
GENITOURINARY: No changes in urine frequency, burning sensation on urination, difficulties in initiating urination, or nocturnal enuresis or dysuria.
NEUROLOGICAL: Denies dizziness, loss of consciousness, nausea, vomiting, ataxia, and paresthesia of syncope.
MUSCULOSKELETAL: Exhibits full ranges of movement in both upper and lower extremities. No joint stiffness or pain.
HEMATOLOGIC: No bleeding problems or prolonged healing of wounds.
LYMPHATICS: No signs of enlarged lymph nodes.
ENDOCRINOLOGIC: Denies polyuria, polyphagia, or polydipsia. No hypothyroidism.

Objective:

Physical exam: Vitals: T- 97.0 P- 70 R 18 116/68 Ht 5’9 Wt 175lbs

Diagnostic results: Routine blood works were ordered to assess the normal functioning of the patient’s different body systems. Such tests include complete blood cell count, lipid profile, blood sugar test, metabolic panel, CRP analysis, thyroid function test, enzyme marker tests, clotting factor and coagulation profile, DHEA, and screening for STDs. Imaging studies like CT scans and x-ray requested for visible malformation. To promote psychiatric diagnosis, screening tools such as the Profile of Mood States (POMS) depression subscale, Generalized Anxiety Disorder 7 (GAD-7), the Center for Epidemiological Studies Depression Scale (CES-D), Beck Depression Inventory (BDI), and the Hamilton Depression Rating Scale (HAM-D) were used (Fisher et al., 2021).

Assessment:

Mental Status Examination: The patient walked into the examination room with confidence, appearing healthy and neat in age-appropriate casual clothing. He is pleasant and very cooperative during the interview. He is alert and well-oriented in person, place, and time. His tone is appropriate with the use of respectful language. His speech is pressured, especially when talking about his sexuality. His mood is flat, and sad at times. He seems confused at the time, but with an unremarkable thought process and judgment. His short-term and long-term memory is intact. His affect is congruent. He reports suicidal thoughts associated with fear of disclosing his sexuality. Denies hallucination, delusion, or suicidal attempts.

Differential Diagnoses:

Social Anxiety Disorder (Social Phobia): Based on the DSM-V criteria, the diagnosis of SAD requires presentations of intense and persistent fear or anxiety caused by a specific stimulus in a social situation which makes one believe that they may be judged differently and embarrassed or humiliated (Campbell et al., 2020). It thus leads to avoidance behavior or enduring the social stimuli with intense fear. The patient in the provided case study reports that his fear is mainly associated with disclosing his sexuality to important people in his life with the fear of being rejected. The patient even claims of having suicidal thoughts about how his friends will react when they realize that he is gay. SAD is thus the most probable primary diagnosis for this patient.
Generalized Anxiety Disorder (GAD): For the diagnosis of GAD, the DSM-V outlines that the patient must present with extreme fear and worry about certain topics, and activities of events for at least 6 months, contributing to other symptoms which are difficult to control (Arbanas, 2020). The patient must also display at least three of these symptoms in the same two weeks, such as restlessness, loss of energy, impaired concentration, sleeping difficulties, irritability, and muscle ache. The patient is negative for most of these symptoms, and only positive for extreme worry and anxiety, hence does not meet the threshold for this diagnosis.
Major Depressive Disorder (MDD): The diagnosis of MDD, according to the DSM-V requires the presence of at least five of the following symptoms within the same period of two weeks including depressed mood, diminished pleasure, weight changes, sleeping problems, psychomotor agitation, and physical symptoms such as GI disturbances among others (Averill et al., 2018). The patient is negative for most of these symptoms except for depressed mood.

Reflections: The PMHNP displayed a high level of psychiatric professionalism when evaluating the 19-year-old patient with symptoms of SAD common among most vulnerable populations such as the gay. Additionally, the clinician should have focused on helping the client build confidence in seeking psychiatric care, by providing available treatment options such as psychotherapy to help with the patient’s mental concerns (Leichsenring & Leweke, 2017). It was, however, clever and necessary to discuss with the patient the HIPAA rules to avoid the incidence of ethical dilemmas on disclosure and no disclosure of the patient information while still upholding their autonomy and confidentiality rights.

References

Arbanas, G. (2020). Anxiety and Somatoform Disorders. Psychiatry and Sexual Medicine, 261–276. https://doi.org/10.1007/978-3-030-52298-8_18

Averill, L. A., Smith, N. B., Holens, P. L., Sippel, L. M., Bellmore, A. R., Mota, N. P., Sareen, J., Southwick, S. M., & Pietrzak, R. H. (2018). Sex Differences in Correlates of Risk and Resilience Associated with Military Sexual Trauma. Journal of Aggression, Maltreatment & Trauma, 28(10), 1199–1215. https://doi.org/10.1080/10926771.2018.1522408

Campbell, J. K., Poage, S. M., Godley, S., & Rothman, E. F. (2020). Social anxiety as a consequence of non-consensually disseminated sexually explicit media victimization. Journal of interpersonal violence, 0886260520967150. https://doi.org/10.1177/0886260520967150

Fisher, K., Seidler, Z. E., King, K., Oliffe, J. L., & Rice, S. M. (2021). Men’s anxiety: A systematic review. Journal of Affective Disorders, 295, 688–702. https://doi.org/10.1016/j.jad.2021.08.136

‌Leichsenring, F., & Leweke, F. (2017). Social anxiety disorder. New England Journal of Medicine, 376(23), 2255-2264. DOI: 10.1056/NEJMcp1614701

Subjective:

CC (chief complaint): “I fear telling others about my sexuality”

HPI: the patient is Mr. Ralph Newsome, a 19-year-old male that came to the psychiatric clinic for psychiatric assessment. The patient is a former military personnel and currently works part time in construction. The patient reports difficulties in telling others about his sexuality. The patient reports that he has been weighing about the benefits and disadvantages of revealing his sexuality as a gay. He fears the ridicule that he would experience from other soldiers after knowing about his sexuality. The patient reports that he has never told anyone about his sexuality, except the psychiatrist. The patient reports that he fears that others will not be comfortable being around him after he tells them his sexuality. The patient denies sexual thoughts about men but reports interest in close relationship with them as well as women. He also acknowledges fear of rejection from others following his disclosure. He reports suicidal thoughts when he was young but denies any recent thoughts, plans, or intention.

Past Psychiatric History: The patient denied any history of psychiatric illnesses

General Statement: I fear telling others about my sexuality
Caregivers (if applicable):none
Hospitalizations: the client denies any history of hospitalization
Medication trials: The client denies any history of medication trials
Psychotherapy or Previous Psychiatric Diagnosis: The client denies any history of psychotherapy or previous psychiatric diagnosis

Substance Current Use and History: The client denies any current or previous use of alcohol, smoking, and other substance use or abuse

Family Psychiatric/Substance Use History: The client denies any history of psychiatric or substance abuse history in the family

Psychosocial History: The client lives alone with his dog. He is the only child in his family. He currently works part time in construction. He has been recalled to Iraq to work as a soldier. The patient reports that his family is his source of social support. He denies any stress. However, he fears telling others about his sexuality.

Medical History: The patient denied any history of hospitalization or surgeries.

Current Medications: The patient is not currently using an medications.
Allergies: The patient reported that he is allergic to Penicillin. He denied food and environmental allergies.

Reproductive Hx: The patient is single. He is not in a relationship. He denies dysuria, frequency and urgency. He also denies any history of sexually transmitted infections or abuse.

ROS:

GENERAL: The patient is dressed appropriately for the occasion. There is no evidence of weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: The patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: He also denies hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: The patient denies rash or itching.

CARDIOVASCULAR: The patient denies chest pain, chest pressure, or chest discomfort. He also denies palpitations or edema.

RESPIRATORY: The patient denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: The patient denies anorexia, nausea, vomiting, or diarrhea. He also denies abdominal pain or blood.

GENITOURINARY: The patient denies burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: The patient denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. He also denies change in bowel or bladder control.

MUSCULOSKELETAL: The patient denies muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: The patient denies anemia, bleeding, or bruising.

LYMPHATICS: The patient denies enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: The patient denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Physical exam:

Vital signs: BP 119/76 P 68 T 36.7 SPO2 98% at room air, RR 20 beats per minute, regular

Respiratory: Presence of clear lung sounds and absence of wheezing, cough, and nasal flaring.

Cardiovascular: Presence of S1 and S2 heart sounds. Absence of adventitious heart sounds and body edema.

Diagnostic results: None

Assessment:

Mental Status Examination: The patient is dressed appropriately for the occasion. He appears of the appropriate weight for his age and gender. He denies fever, fatigue, or chills. The patient is alert and oriented to self, others, time, and events. The thought process is intact and future oriented. The patient maintains normal eye contact during the assessment. He demonstrates speech of normal tone and rate. The patient does not demonstrate abnormal mannerism such as tremors and tics. The patient denies illusions, delusions, and hallucinations. His mood is anxious. The patient denies suicidal thoughts, plans, or attempts.

Differential Diagnoses:

Social anxiety disorder: Social anxiety disorder is the client’s primary diagnosis. Social anxiety disorder is a mental health disorder that is characterized by significant anxiety or fear about social situations that a patient is exposed to potential scrutiny by others. Patients may have fear or anxiety in talking about or being observed in social situations involving others. The social situation or encounter often results in fear or anxiety, which are beyond the actual threat associated with the situation and to its sociocultural context. The fear and anxiety results in avoidance of situations that predispose the patient to the problem. There is also the impairment in social or occupational functioning and distress. The symptoms persist for at least six months and cannot be attributed to causes such as medications use, mental health problems, or substance use and abuse (Koyuncu et al., 2019; Rose & Tadi, 2023). The patient in the case study has significant fear and anxiety towards revealing his sexuality. He fears rejection and the unknown reaction by his colleagues. The fear affects his interaction with others in his work as a soldier. Therefore, social anxiety disorder qualifies as the primary diagnosis.

Generalized anxiety disorder: Generalized anxiety disorder is the client’s secondary diagnosis. Generalized anxiety disorder is a mental disorder that is characterized by excessive fear or worrying about things or events. The fear and worry are beyond the patient’s control. Patients may also report accompanying symptoms such as restlessness, fatigue, and difficulty in concentrating among others. The patient in the case study demonstrates excessive fear towards revealing his sexuality. He fears the repercussions associated with his decision to inform others about his sexualty. The fear the patient has cannot be attributed to medication use, a medical condition or substance abuse (DeMartini et al., 2019). However, the client does not have the accompanying symptoms such as restlessness, making generalized anxiety disorder a secondary diagnosis.

Post-traumatic stress disorder: Post-traumatic stress disorder is the other differential diagnosis that may be considered for the patient. Patients with this disorder experience avoidance, fear, and anxiety symptoms (Lewis et al., 2020). However, it is the least likely cause of the client’s problem since the client does not have any related traumatic experiences or exposures.

Obsessive compulsive disorder: The other secondary diagnosis to be considered for the patient is obsessive compulsive disorder. Patients diagnosed with obsessive compulsive disorders often experience obsessive thoughts that result in compulsions and repetitive behaviors (Goodman et al., 2021). However, this is a least likely cause of the patient’s problem because of the lack of obsessions, compulsions, and repetitive behaviors.

Panic disorder: Panic disorder is the last potential diagnosis that should be considered for the patient. Panic disorder is a mental health disorder characterized by experiences of intense panic or fear towards situations. Panic disorder is the least likely cause of the client’s problem because of the lack of sudden, intense fear or panic and associated symptoms such as shortness or breath or palpitations (Breilmann et al., 2019).

Reflections:I agree with the nurse preceptor’s diagnosis. The symptoms the client has are similar to those seen among patients diagnosed with social anxiety disorder. One of the things that I would do differently should I experience a similar situation is initiating a patient with social anxiety disorder on treatments such as group or individual posychotherapy. Psychotherapy would help the patient to develop effective coping strategies against the triggers of the disorder. I am interested in researching more about the effect of sociocultural factors on the decisions of the patients to reveal their sexuality.

References

Breilmann, J., Girlanda, F., Guaiana, G., Barbui, C., Cipriani, A., Castellazzi, M., Bighelli, I., Davies, S. J., Furukawa, T. A., & Koesters, M. (2019). Benzodiazepines versus placebo for panic disorder in adults. Cochrane Database of Systematic Reviews, 3. https://doi.org/10.1002/14651858.CD010677.pub2

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder. Annals of Internal Medicine, 170(7), ITC49–ITC64. https://doi.org/10.7326/AITC201904020

Goodman, W. K., Storch, E. A., & Sheth, S. A. (2021). Harmonizing the Neurobiology and Treatment of Obsessive-Compulsive Disorder. American Journal of Psychiatry, 178(1), 17–29. https://doi.org/10.1176/appi.ajp.2020.20111601

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