Week (#): Assessing and Diagnosing Patients with Anxiety Disorders, PTSD, and OCD Essay

Week (#): Assessing and Diagnosing Patients with Anxiety Disorders, PTSD, and OCD Essay

NRNP 6635: Psychopathology and Diagnostic Reasoning

 

Subjective:

CC (chief complaint): “I went to the emergency department because I was feeling like I was dying from a heart attack, was sweating, irrational fear, had a problem catching my breath, and the heart felt like it was pounding out of the ribcage.”

HPI: The patient was okay until a week ago when he started feeling like he was dying from a heart attack, sweating, having trouble sleeping, and precipitations. The client had another episode recently when preparing coffee. The sudden and unpredictable symptoms are not aggravated or relieved by any specific factors. The symptoms disappear on their own after some time. The patient also feels apprehensive and explains that the symptoms are severe. The client reports that her mother had similar symptoms, which were not caused by any specific reason.

Past Psychiatric History:

• General Statement: The patient was received in an emergency department last week after an episode of fear and feel like dying. An EKG showed that his heart activity was normal
• Caregivers (if applicable): None
• Hospitalizations: None
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History: No history of current or past substance use history

Family Psychiatric/Substance Use History: Mother had similar symptoms of impending doom in the past. No other family history of psychiatric illness

Psychosocial History: The patient was born in Buffalo, New York, and is the only child in the family. He lives in Orlando, Florida. The client has a girlfriend but lives alone. He is a student studying graphic design at college. He works as a part-time uber driver. The client has no adult or childhood trauma history. He also denies suicidal ideations or behaviors. The patient also denies any past or current history of legal issues.

Medical History:

• Current Medications: The patient is not on any current medication
• Allergies: The patient has no known drug or food allergies. Denies cold or heat intolerance

• Reproductive Hx: The patient has a girlfriend and is interested in heterosexual relationships

ROS:

• GENERAL: The patient denies recent weight loss, fever, or chills.
• HEENT: Head: Denies headaches, Hair loss, or pain. Eyes: Denies eyesight loss, pain, drainage, irritation, dryness, or itchiness.
• SKIN: Denies rashes, itchy, or broken skin
• CARDIOVASCULAR: Complaints of chest tightness, palpitations, and chest discomfort occasionally. Denies edema
• RESPIRATORY: Reports occasional shortness of breath and denies cough or sputum production
• GASTROINTESTINAL: Denies anorexia, nausea, vomiting, pain, blood in stool
• GENITOURINARY: Denies burning micturition, urinary urgency or frequency, odor or color
• NEUROLOGICAL: The client denies headache, dizziness, paralysis, ataxia, or tingling sensation in the extremities. Denies any changes in bladder control
• MUSCULOSKELETAL: Denies muscle or joint pain, tightness
• HEMATOLOGIC: Denies easy bruising, anemia, or bleeding
• LYMPHATICS: Patient denies any enlarged lymph nodes or splenectomy
• ENDOCRINOLOGIC: Patient denies sweating, cold or heat problems, polyuria, or polydipsia

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Objective:

Physical exam:

Vitals: Temp: 97.4 P: 112 RR:22 BP: 122/68 Ht: 6’1and Wt: 198lbs

General Appearance: The patient appears stressed, is assertive, well-groomed, and

HEENT: Head: Normocephalic, intact hair with no hair loss, atraumatic head. Eyes- no drainage, pain, and vision is 20/20 bilaterally. Ears- no drainage or pain, and the whisper test is positive bilaterally. Nose: no pain, drainage, or sinus pain, and the nasal membrane is pink. Throat: membrane pink, no deposits, and ovula midline

Neck: No enlarged regional lymph nodes or pain. Neck has a full range of motion and no edema.

Chest: No palpitation S1 and S2 with no murmurs. Symmetrical chest movement with breathing. Apical pulse 112.

Abdomen: globular in shape, no engorged veins or flank discoloration. No tenderness or masses. Liver and spleen not enlarged

Diagnostic results: EKG shows a normal heart function. Cortisol level assessment helps determine the stress levels in the blood. Other tests include an encephalogram, cardiac troponins, urinalysis, and blood culture.

Assessment:

Mental Status Examination: The patient is assertive, well-groomed, and dressed for the occasion. He is calm and cooperative throughout the encounter. His mood is sad/euthymic, and the effect is broad and congruent. The patient does not exhibit movements, such as tics and hand gestures. The patient denies any visual or auditory hallucinations. The thought process is goal-directed and logical, with no delusions. He denies current or past suicidal ideations or tendencies. His speech is clear, coherent, and has good volume and tone. He is oriented to time, place, person, and circumstance. His immediate recall and retention, recent, and remote memory are intact. His concentration and attention are intact. He has complete insight into the problem, acknowledges its existence, and expresses a need for help. He has good judgment. The client denies any changes in appetite, sleep (sleeps for an average of 6 hours), or sex drive.

Differential Diagnoses:

Panic Disorder: Panic disorder is an anxiety problem characterized by panic attacks regularly. Panic attacks are critical in diagnosing panic disorder. Perrotta (2019) notes that expected panic attacks associated with specific activities, such as fear of heights, are exempted from the panic disorder diagnosis, while unexpected panic attacks have no apparent triggers and can occur at any time and from the blues. According to the DSM-5, panic disorder is characterized when by any four symptoms of; palpitations, pounding heart, tachycardia, sweating, trembling or shaking, sensations of shortness of breath, a feeling of choking, nausea, and abdominal distress, feeling dizzy lightheadedness, derealization, depersonalization, fear of losing control, numbness, chills, hot flushes, or fear of dying (APA, 2022). The patient presents with more than six symptoms, including the fear of dying, sensations of shortness of breath, sweating, high heart rate (112 bpm), fear of losing control, and chest discomfort.

Generalized Anxiety Disorder: Generalized anxiety disorder is characterized by excessive anxiety and worry, increased muscle aches, impaired concentration, restlessness, irritability, and difficulty sleeping. In GAD, the symptoms are not associated with any specific cause, and the client may seem depressed. The condition may be confused with depression when care providers fail to perform a clinical assessment. Other disorder symptoms include restlessness, frequent tiredness, poor concentration, easy irritability, muscle tension, and sleep problems. According to the DSM-5, GAD is diagnosed when there is excess anxiety ad worry for less than six months and is excessive and is related to many events, situations, or activities (Price et al., 2019). In addition, 3 of these symptoms must have been present for this patient for more than six months. The client in this case study has excessive worry, but the excessive worry is associated with palpitations and a sense of impending doom in sudden outbursts. In GAD, the symptoms are continuous; for this patient, the symptoms appear in sudden attacks, hence ruling out GAD. The patient also denies sleeping, tiredness, and concentration problems which are hallmarks of a generalized anxiety disorder (Khan et AL., 2018).

Post-Traumatic Stress Disorder: Post-traumatic stress disorder is an anxiety problem triggered by terrifying events whereby the client witnesses experiences. Symptoms associated with the disorder include flashbacks, nightmares, and extreme worry or uncontrollable thoughts regarding the event. According to the DSM-5, PTSD is diagnosed by recurrent, involuntary, intrusive memories, traumatic nightmares, flashbacks, intense distress, and marked reactivity to stimuli (APA, 2022). These symptoms often present alongside panic attacks. Price et al. (2019) note that individuals with PTSD also present with panic attacks characterized by palpitations, shortness of breath, and hot flashes caused by re-experiencing the trauma. Bryant (2019) notes that patients can have thoughts or dreams that cause lead to panic attacks, which are specific and core symptoms in diagnosing the disorder. However, this patient reports no past traumatic experience and says that the panic attacks are not precipitated by any event hence ruling out the diagnosis.

In addition to these differentials, the conditions should be differentiated from medical conditions such as arrhythmia, myocardial infarction, pericarditis, asthma, hypoglycemia, seizure disorder, and transient ischemic attacks. Laboratory tests and imaging studies are essential in diagnosing or ruling out disorders (Sadock et al., 2015). Laboratory and imaging studies such as EKG, cardiac stress test, and encephalography help rule out other conditions.

Reflections

During the assessment, I learned a lot from the interaction. I learned that open-ended questions are the best in assessing patients because it allows them to give answers and perspectives on their health. In addition, I learned the presentations might not be differentiated by some clinical manifestations but by a group of clinical presentations. In the future, I will implement cultural considerations and assess the factors surrounding patient presentations. Understanding the patient’s life and circumstances, such as stress and flawed social relationships, can impact the diagnosis process and lead to effective treatment. I will focus on the patient’s history and evaluate it exclusively for cues in the patient’s past life that could assist in making an accurate diagnosis. According to Bethell et al. (2019), childhood and past traumatic experiences can impact clients’ anxiety and mood disorder development.

A non-judgmental attitude when diagnosing patients is necessary to ensure all information is collected and utilized in the patient’s management. Another ethical consideration is ensuring patients have access to quality care and effective treatment interventions. Issues such as the costs of medications are also essential to ensure clients afford and adhere to prescribed medications.

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References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787

Bethell, C., Jones, J., Gombojav, N., Linkenbach, J., & Sege, R. (2019). Positive childhood experiences and adult mental and relational health in a statewide sample: Associations across adverse childhood experiences levels. JAMA Pediatrics, 173(11), e193007-e193007. https://doi.org/10.1001/jamapediatrics.2019.3007

Bryant, R. A. (2019). Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges. World Psychiatry, 18(3), 259-269. https://doi.org/10.1002/wps.20656

Khan, I. W., Juyal, R., Shikha, D., & Gupta, R. (2018). Generalized anxiety disorder but not depression is associated with insomnia: a population-based study. Sleep Science, 11(3), 166. https://doi.org/10.59351984-0063.20180031

Price, M., Legrand, A. C., Brier, Z. M., & Hébert-Dufresne, L. (2019). The symptoms at the center: Examining the comorbidity of post-traumatic stress disorder, generalized anxiety disorder, and depression with network analysis. Journal of Psychiatric Research, 109, 52-58. https://doi.org/10.1016/j.jpsychires.2018.11.016

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

LEARNING RESOURCES
Required Readings
American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disorders

Links to an external site.
(5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders
American Psychiatric Association. (2022). Obsessive compulsive and related disorders In Diagnostic and statistical manual of mental disorders

Links to an external site.
(5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x06_Obsessive_Compulsive_and_Related_Disorders
American Psychiatric Association. (2022). Trauma- and stressor-related disorders.. In Diagnostic and statistical manual of mental disorders

Links to an external site.
(5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders
Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
Chapter 9, Anxiety Disorders

Chapter 10, Obsessive-Compulsive and Related Disorders

Chapter 11, Trauma- and Stressor-Related Disorders

Chapter 31.11 Trauma-Stressor Related Disorders in Children

Chapter 31.13 Anxiety Disorders in Infancy, Childhood, and Adolescence

Chapter 31.14 Obsessive-Compulsive Disorder in Childhood and Adolescence

COURSE TEXT
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
Note: This required text is available for purchase. It is also accessible through the Walden Library.
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

ASSESSING AND DIAGNOSING PATIENTS WITH ANXIETY DISORDERS, PTSD, AND OCD
“Fear,” according to the DSM-5-TR, “is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (APA, 2022). All anxiety disorders contain some degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event. Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is a chronic hyperarousal of the stress response, making the individual vulnerable to further stress and stress-related disease.

For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5-TR criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5-TR criteria.

TO PREPARE:
Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing anxiety, obsessive-compulsive, and trauma- and stressor-related disorders.
Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.

I have uploaded five files: a video to use for the assignment, a case history for the video, a template, an exemplar template, and a rubric.

Please be mindful of plagiarism.