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Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper

Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper

Comprehensive Psychiatric Evaluation of a 27 Year-Old War Veteran (Sergeant Berry Sullivan) with Post-Traumatic Stress Disorder (PTSD)

Subjective:

CC: The client arrives at the treatment center alone and states that his girlfriend insisted he comes for treatment. They had gone out to a fair and sudden cracking of fireworks sent him scampering for safety. He states that he is easily startled, experiencing nightmares about the battlefield every day, hating the smell of diesel “like that of a chopper,” recalling the smell of burning human flesh when a family member singed their hair, being afraid of being stuck in a traffic jam and imagining someone throwing an IED under the car. He is also afraid of going out to public places such as malls or restaurants. As a result, he likes to spend most of his time indoors. Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper

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HPI: The client is a 27-year-old Caucasian male who served in the military as a sergeant. He claims to have suffered the aforementioned symptoms since returning from service. He observed the onset of the problems as soon as he returned from the battle. His thoughts are the source of his symptoms. The complaints are ongoing, since he claims to be afraid all of the time. All he wants to do is stay inside. They are persistent and repeated, as is typical. They are exacerbated by being in the presence of a large crowd or by being stuck in traffic. When he is alone in the room all day, the symptoms subside considerably. He notices the symptoms any time day and night; but the nightmares come at night in the form of dreams every day. He believes the severity of his symptoms is at 8/10 on a scale. Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper

Past Psychiatric History:

  • General Statement: He served in the military and was sent to war severally. He is still traumatized by what he saw and heard. For instance, improvised explosive devices or IEDs exploding and killing his colleagues.
  • Caregivers: He seems not to need any caregivers at the moment because he is not dysfunctional for self yet.
  • Hospitalizations: He has never been hospitalized for psychiatric reasons or otherwise.
  • Medication trials: He has never been put on any psychiatric treatment or medications.
  • Psychotherapy or Previous Psychiatric Diagnosis: He has not been diagnosed with mental illness before this visit. For that reason, he has also never been on any form of psychotherapy.

Substance Current Use and History: He denies smoking or using any banned substances. He drinks only occasionally at home since he is afraid of crowded places.

Family Psychiatric/Substance Use History: He has no significant family history of substance use or mental illness.

Psychosocial History: The sergeant is engaged but has no children yet. They share a home with the girlfriend with whom he is about to get married and her mother. He avoids going out because he is terrified of crowds. His girlfriend, on the other hand, occasionally takes him out, such as to the carnival. They stay in a good neighborhood with all the amenities required. There are smoke detectors in the house. He uses a seatbelt all the time when riding in a care and also does not use his phone when driving.

Medical History: Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper

  • Current Medications: He not on any drugs or medications presently.
  • Allergies: He has no known allergies.
  • Reproductive Hx: He describes himself as a heterosexual male but does not have any children yet

ROS:

  • GENERAL: Denies fatigue, weakness, chills, fever, and weight loss.
  • HEENT: Negative for photophobia, otorrhea, tinnitus, rhinorrhea or a sore throat.
  • SKIN: Denies rashes, itching, or eczema.
  • CARDIOVASCULAR: Negative for chest discomfort and/ or edema of the extremities.
  • RESPIRATORY: Negative for shortness of breath, coughing, or producing sputum.
  • GASTROINTESTINAL: Denies nausea, vomiting, or diarrhea.
  • GENITOURINARY: Denies frequency, hesitancy, or painful micturition.
  • NEUROLOGICAL: Denies numbness, dizziness, syncope, or paraesthesia.
  • HEMATOLOGIC: Denies a family history of blood or clotting disorders.
  • LYMPHATICS: Negative for lymphadenopathy and splenectomy.
  • ENDOCRINOLOGIC: Negative for excessive thirst, excessive drinking of alcohol, excessive sweatness, previous hormonal therapy, and heat/ cold intolerance.

Objective:

Physical exam:

Vital signs: T- 98.8 P- 86 R 18 B/P 122/7 Ht 5’8 Wt 160lbs

Diagnostic Results and Laboratory Tests: Laboratory tests and radiological examination reveal no physical illness. The Hamilton Anxiety Rating Scale (HAM-A) performed revealed a score of 29. This is severe anxiety Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper.

Assessment:

Mental Status Examination (MSE)

The client is a 27-year-old military vet who is aware of person, location, space, and incident. His discourse is clear, concise, and purposeful. His clothing is suitable for the time of day and climate. He appears to be in mental distress, and his self-reported mood is “anxious.” The affect is dysphoric and in sync with the above mood. There are no discernible tics, idiosyncrasies, or gestures. He is free of hallucinations and delusions. He also shows no suicidal or homicidal tendencies. Insight and judgment are still unaffected. The diagnosis made is Post-Traumatic Stress Disorder or PTSD (APA, 2013; Sadock et al., 2015)Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper.

Differential Diagnoses

Post-traumatic Stress Disorder (PTSD): Given the patient’s symptoms and his background as a war veteran, this is the most appropriate diagnosis. Being confronted by death or a threat of death or serious injury, having memories, nightmares, or flashbacks of past traumatic experiences, continuously attempting to avoid any sensory inputs related to the trauma, negative cognitive changes, changes in reactions such as hypervigilance and an exaggerated startle reflex, impairment in social and other functions, symptoms not attributable to drug use or a medical condition, and the above symptoms lasting more than one month (APA, 2013; Sadock et al., 2015)Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper.

Major Depressive Disorder or MDD: A traumatic incident is usually followed by major depressive disorder, or MDD. It is defined by DSM-5 diagnostic criteria such as persistent depression, feeling inadequate, self-blame, contemplation of death and dying, and social exclusion, among others (APA, 2013; Sadock et al., 2015). However, this diagnosis is improbable to be the primary one because MDD does not include category B and C characteristics like PTSD. Those are, intrusive and uncomfortable memories of traumatic events in the past, as well as aversion of stimuli linked with such events (APA, 2013; Sadock et al., 2015)Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper.

Psychotic Disorder: Psychotic disorders are characterized by hallucinations and illusions that might be difficult to distinguish from flashbacks at times. These perceptual distortions are a feature of DSM-5 diagnostic criteria for disorders such as schizophrenia. However, it differs from PTSD in that there has been no previous experience of a traumatic event (APA, 2013; Sadock et al., 2015)Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper.

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Reflection

This full psychiatric assessment was carried out by myself utilizing evidence-based procedures for background collection and physical assessment (Ball et al., 2019; Bickley, 2017). As a result, if given the opportunity again, I would proceed in the same manner. Ethical considerations included obtaining informed consent from the patient through autonomy (Haswell, 2019). Also, I ensured that the other ethical principles of nonmaleficence (to do no harm), beneficence, and justice were respected. In terms of health education, I advised the patient to complete all CBT appointments and take part in group therapy to benefit from group therapeutic elements such as altruism, instillation of hope, interpersonal learning, self understanding, universality, group cohesiveness, catharsis, and imitative behavior amongst others (Hauber et al., 2019)Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper. I also encouraged him to begin participating in things such as athletics or other such pastimes so that he does not have time to reflect on the past traumatic experiences. 

References

American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177 Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper

Hauber, K., Boon, A.E., & Vermeiren, R. (2019). Therapeutic factors that promote recovery in high-risk adolescents intensive group psychotherapeutic MBT programme. Child and Adolescent Psychiatry and Mental Health, 13(1), 1-10. https://doi.org/10.1186/s13034-019-0263-6

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.

Training Title 21(2016). [Video/DVD] Symptom Media. https://video.alexanderstreet.com/watch/training-title-21 Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper

 Training Title 21

Name: Sergeant Berry Sullivan
Gender: male Age:27 years old T- 98.8 P- 86 R 18 B/P 122/7 Ht 5’8 Wt 160lbs
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) six months ago after eight years of service. He is engaged to be married in 8 months and is using his GI Education Bill to attend an online college for accounting. 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 “abusive when he was drunk.”
Father is still alive, unwell (DM, cirrhosis, HTN), and 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. He has one younger brother 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. Has service-connected asthma, seasonal allergies; no hx of psychiatric or substance use treatment. Symptom Media. (Producer). (2016)Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper.

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

Please Click on Direct Link to complete case you must log in to Walden Website to view the complete viewing of this case (session is 12 minutes long): Training Title 21 – Alexander Street, a ProQuest Company (openathens.net) Case Study For War Veteran With Post-Traumatic Stress Disorder Essay Paper