CASE ANALYSIS EVALUATION

Chief complaint: “My wife wants me to get help”

HPI: Andrew is a 59 Years old male who presents to the outpatient mental health clinic with a complaint of depressed mood most of the time with a high level of irritability, anger outbursts and gets aggravated easily. He says that he is seeking help because his wife has threatened divorce if he does not seek treatment. He reports frequent episodes of intrusive thoughts about past combat experience in Vietnam. The symptoms have worsened after the Iraq war started. He tries to avoid watching the news, and other things that remind him of his military service in Vietnam when possible. He denies panic attacks, vegetative symptoms of depression, hallucinations, and paranoia. He reports frequent feelings of being closed in and needing to get fresh air to obtain relief. He reports a lack of trust in others and does keep a distance from others. He reports feeling uncomfortable and guarded in crowds. Andrew says does not sleep well due to frequent nightmares, which consist of a recurring dream theme of being captured, and executed as a soldier. Denies sudden weight loss, excessive sweats, hair loss, and chronic fatigue.

Psychiatric History: Andrew first sought psychiatric treatment 8 years ago. He was prescribed sertraline which helped some but unable to tolerate dose higher than 100mg dose. He took the medication for about two years and stopped because he felt it was not helping anymore. He was referred to therapy but did not show up to the appointment.

 

Past Medical History: GERD, HTN

Surgical History: None

Family Medical History: Mother- Anxiety, HTN; died at age 70.  Father- Alcoholism; died at age 65-years. Brother- COPD, tobacco smoker. Sister has anxiety

Social History:  Lives with the wife of 30 years and two dogs. Has two adult daughters who live out of state. He was raised in the Baptist faith but does not attend church regularly. He feels like God hates him and says heâ€s angry at God. Drinks alcohol 2-3 beer on weekends. Denies illicit drug use. Denies history of tobacco use. Denies legal history.

Educational/Occupational History: He graduated high school at age 17 and went to live with an older brother. He worked in construction for about a year and then later drafted into the Military. He was in the Military for five years. His longest employment was nine years of construction work. He has held about 15 jobs in his lifetime. He considers himself a carpenter. He is currently unemployed and supported financially by a wife who works as a school teacher.

Developmental/Family History– Andrew is the second of three children. He was born and raised on a farm and his parents had little money. He described childhood as happy and fun. He denies developmental problems. He had a good relationship with siblings, and they all worked on the family farm together after school. He described his parents as hardworking. Although the father struggled with alcoholism, he was still able to work and provide for the family.

Review of Systems:  10-system ROS negative except symptoms noted in HPI.

Medications:  Sertraline (SSRI)

Allergies:  NKDA

Vital Signs:  BP 110/60 HR 65bpm, T 98.9F, RR 18/min Weight 160lbs without significant recent changes. 

 

Instructions:

 

  Etiology: Delineate the etiology of each of the four differential diagnoses. Include psychosocial factors and past experiences that may be contributing to current symptoms.

 Diagnostic Screening Tools:  Delineate what diagnostic screening tools would be appropriate for each of the four differential diagnoses.

 

Please find the etiology and diagnostic screening tools for the four differential diagnoses

 

1.           PTSD

2.           GAD

3.           IED

4.           Antisocial personality disorder

 

PTSD AS THE MAIN DIAGNOSIS