Assessing and Diagnosing Patients with Anxiety Disorders, PTSD, and OCD

Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample

Comprehensive Psychiatric Evaluation

Patient: F.I.

Age: 47 years

Gender: Female

CC: “I can barely sleep and constantly over-worry, and I am glued to the TV the whole day. I fear I might lose my children. I need to protect, and I am doing what I need to do.”(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Subjective (S):

HPI: F.I. is a 47-year-old female presenting at the clinic with complaints of sleeping difficulties and being glued to the TV throughout the day after a recent school shooting in the neighborhood three weeks ago by her husband. This incident “flipped a switch” in her because she had barely slept since then. She decided to homeschool her children. The patient reports recent killings and insecurity in schools and the country as reasons for homeschooling her children. She worries about her kids and thinks responsible people like the school administration are not doing enough. The patient admits to seeing the children’s faces and complains that her husband is heartless for sending her to a “shrink.” She is worried that shooters are so close to her household. She has been homeschooling her children for two months before the interview. She says she fought with her husband about homeschooling, her children are learning more, and her girlfriends, as frightened as her, are also considering doing the same. Her parents died in a car accident due to a drunk driver, and she now fears losing people. Her fears have been increasing recently. Her appetite has decreased. The patient has not previously experienced mental health problems and reports not using substances. She has no family history of mental health or substance use problems. The patient has a history of hysterectomy, no known drug allergies, and has not been involved in legal issues. (Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)    

Social Hx: The patient was born in Northern Ireland before the family, including parents and one sister, moved to the US 15 years ago. Her parents are dead from a car accident caused by a drunk driver. She has a university degree and a master’s degree. She met her husband at university; they now live in Charleston; SC. Patient reports no family history of mental health or substance abuse issues.  (Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Legal Hx: No legal history

Medical Hx: No medical history.

Surgical Hx: History of hysterectomy.

Psychiatric Hx: Patient has no history of mental health or substance abuse treatment.  

Psychiatric medication use: No medication Hx. 

Substance Abuse History: Patient denies any alcohol or substance use.

MSE: Mrs. F.I. came for psychiatric evaluation. Patient was appropriately dressed for the occasion and time of year. She remained seated throughout the interview but was restless, hyperverbal, distressed, and upset. Patient-reported sleeping difficulties and paranoid thoughts. She denied auditory/visual hallucinations and suicidal/homicidal ideations. Patient reports increasing fear and worry about losing her children.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Hospitalization Hx: No hospitalization hx.

ROS:

General: Denies weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Skin: No rash or itching.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Respiratory: Denies wheezes, shortness of breath, consistent coughs, and breathing difficulties while resting.

Gastrointestinal: Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood. Appetite is decreased.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Genitourinary: Denies burning on urination, urgency, hesitancy, odor, odd color

Neurological: Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. Denies difficulties concentrating and paying attention.

Musculoskeletal: Denies muscle, back pain, joint pain, or stiffness.

Hematologic: Denies anemia, bleeding, or bruising.

Lymphatics: Denies enlarged nodes. No history of splenectomy.

Endocrinologic: Denies sweating. No reports of cold or heat intolerance. No polyuria or polydipsia.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Allergies: NKDA.

Objective (O):

Vitals: T- 98.0 P- 82 R 18 136/62 Ht 5’0 Wt. 123lbs

General appearance: FI looks healthy and well-nourished. Patient interacts and converses with the medical care team normally but seems upset. She appears distressed, tensed, unease, confused at the beginning of the interview, and hyperverbal. She is not comfortable.

Cardiovascular: heart rates and rhythm are regular, and murmurs and extra sounds can be heard from the patient’s chest. Has a normal pulse rate throughout, and capillaries refill in 2 seconds.   

Respiratory: no wheezes, and respirations are easy and regular.

Neurological: balance is stable, gait is normal, posture is erect, the tone is good, and speech is clear.

Psychiatric: Patient is upset, and the conversation with the psychiatrist is tense at the beginning of the interview. She is aware and alert of place, situation, and self. Patient is distressed, appears confused, and tensed. She seems to admit forgetfulness of late as she searches for her cell in her bag and cannot find it, which she says is unusual. Patient is fearful and in constant worry.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Neuropsychological testing: the patient continuously over-worries, is fearful, and appears tense. She pays attention but struggles and maintains concentration during the interview.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

ASSESSMENT:

Mental Status Examination: The patient is a 47-year-old white female presenting with increasing worry and fear of losing her children to school violence. The patient indicates appropriate attention to detail, sustains attention to activities, and listens continuously when spoken to directly. The patient follows through on conversation and organizes tasks and thoughts appropriately. The patient is alert to extraneous stimuli, indicates good memory, and engages in appropriate turn-taking during the interview. The patient gives multiple facts and statistics about recent school violence and other violence that she watched on TV. The patient displays paranoid thinking and denies suicidal or homicidal ideation. The patient is alert and oriented, her short-term memory is intact, and her insight is good. The patient indicates disturbing thoughts from the recent school shooting. She indicates fear and worries that the recent school shooting was 100 miles from her home. She appears distressed, tense, and upset that she does not have her phone to call her children.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Primary Diagnosis

F43.1. Posttraumatic Stress Disorder (PTSD)

PTSD is associated with previous exposure to an actual or threatened injury, death, sexual abuse, or other traumatic events. It is disabling and impacts an individual’s life. PTSD is linked to functional and cognitive impairment. The long-term outcomes are detrimental, and early diagnosis is recommended. PTSD patients report reliving the traumatic event, flashbacks, detachment from reality, severe negative thoughts, paranoia, nightmares, and intrusive thoughts. Other symptoms include avoidance, hypervigilance, heightened startle response, increased reactivity, sleeping problems, and irritability (Mann & Marwaha, 2022). FI reports difficulty sleeping, paranoia, seeing the children’s faces, hypervigilance, increased reactivity, increased startled response, negative emotions, and intrusive thoughts. She says she fears losing her children because she lost her parents in a road accident caused by a drunk driver. These events and symptoms confirm PTSD because the DSM-5 criteria require direct or indirect exposure to a traumatic event and symptoms like an intrusion, negative emotions and thoughts, avoidance, and reactivity and arousal changes.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)  

Differential Diagnosis  

1. F41.9. Generalized Anxiety Disorder

PTSD can co-occur with Generalized Anxiety Disorder (GAD). PTSD can increase GAD symptoms or the other way around. Many symptoms of PTSD and GAD are similar, and it can be challenging to distinguish the two. GAD patients report excessive, exaggerated anxiety and over-worrying most of the day without a particular cause or reason (Munir et al., 2021). GAD can occur at any point in life, but it develops. It commonly develops between childhood and middle age. The exact cause of GAD is unestablished. Risk factors include biological factors, family history, life experiences, and other stressors. GAD diagnosis involves looking for signs like severe, continuous worry and tension, unrealistic perceptions of things, restlessness, concentration or attention issues, fatigue, heightened irritability, sleeping problems, and muscle tension (Munir et al., 2021). GAD patients often perceive looming doom and over-worry daily, including about normal things like working. GAD is identified when a person has uncontrollable worrying. GAD was refuted because the constant worry and fear in FI are linked to the death of her parents and the recent school violence incidences.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

2. F43. 0. Acute Stress Disorder (ASD)

PTSD is very similar to acute stress disorder (ASD). However, ASD is shorter in duration. ASD symptoms begin immediately after a traumatic incident, lasting between days and one month. Symptoms beyond one month indicate PTSD. PTSD and ASD symptoms often overlap. Patients report intrusion symptoms like flashbacks, repetitive dreams, mental or physiological distress, negative mood, dissociation from self and emotions, avoidance, sleeping issues, irritability, abnormally alert to surroundings, distractibility, and strong reflective reactions (Fanai & Khan, 2020). The diagnosis was refuted because symptoms associated with the traumatic events lasted more than one month.  (Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

3. F32. Depression

Depression is common morbidity in people with PTSD. Therefore, depression and PTSD can co-exist. Depression can impact functionality. Depression impacts mood, leading to continuous sadness, feelings of worthlessness, hopelessness, and loss of interest. People with depression report experiencing severe sadness, emptiness, and irritable mood. Additionally, patients report somatic and cognitive changes that impact their functionality (Chand et al., 2021). FI reports the previous loss of her parents due to an accident, which made her fearful of losing people. It implies she might not have dealt with grief or is still grieving about her parents. She indicates an irritable mood and hopelessness regarding school insecurity but does not indicate constant sadness and feelings of emptiness and worthlessness, which makes depression unlikely.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Plan (P): Early detection and intervention are crucial for PTSD management planning. A combination of psychotherapy and pharmacology is an effective treatment(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Therapeutics:

Pharmacological Interventions: Selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) are used to treat PTSD as first-line drugs (Mann & Marwaha, 2022). FDA-approved medications, including sertraline and paroxetine, are effective in adults. Clonidine and prazosin will help decrease trauma-related nightmares, like seeing the children’s faces and imagining they would be hers. Trazodone is effective in treating insomnia (Mann & Marwaha, 2022). The patient should follow adequate sleep hygiene for optimal results. (Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Therapy: Trauma-focused psychotherapy is recommended in treating PTSD as the first-line treatment. The patient will undergo trauma-focused cognitive behavioral therapy, reprocessing, and eye movement desensitization. The patient will also undergo cognitive processing therapy and imaginal exposure to improve PTSD symptoms and increase coping behavior and capacity (Mann & Marwaha, 2022). Therapy will help change the long-term outcome of the trauma of losing parents and reduce recovery time.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Education:

1. Educate patient and family regarding medication side effects and adverse events that can prompt seeing a physician.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)
2. Educate patient and family on medication adherence and working mechanisms of medication, and what to avoid when medicating.
3. Advise the patient and family on the need for a support group with members experiencing the same fears.
4. Engage the patient in skills training and coping strategies.
5. Educate patients on strategies to eradicate negative thoughts and emotions and embrace positive thinking.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)
6. Educate the patient and family on the need to work together and remain in harmony.

Further assessment is to develop a comprehensive care plan.

Consultation/follow-up: The patient should report back to the clinic in a week for further assessments

Reflection

The patient is a 47-year-old female experiencing constant worry and fear of losing her children. She lost her parents and now fears she can lose her children due to school violence. Her current indications imply PTSD. This condition is challenging to diagnose because of other disorders like GAD and ASD that have overlapping symptoms and might co-occur with PTSD. However, DSM-5 criteria offer a clear line of accurate diagnosis. GAD is not associated with particular events, and constant fear and worry have no specific reason. ASD symptoms last less than a month; otherwise, PTSD is confirmed. Depression and PTSD are not very similar, but they can co-occur, impacting diagnosis. This activity and assessment increased my understanding of PTSD and how different patients respond differently to traumatic events. It also shows that loss and PTSD are interconnected. Given another chance with the patient, I would inquire more about how she dealt with her grief after losing her parents, her support system, and how she feels about the incident now, including how the loss impacted her life. This inquiry would help develop a more comprehensive treatment plan.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

References

Chand, S. P., Arif, H., & Kutlenios, R. M. (2021). Depression (Nursing).(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Fanai, M., & Khan, M. A. (2020). Acute stress disorder. StatPearls [Internet].(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Munir, S., Takov, V., & Coletti, V. A. (2021). Generalized Anxiety Disorder (Nursing). StatPearls [Internet].(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

Mann, S.K., & Marwaha, R. (2022). Posttraumatic Stress Disorder. StatPearls [Internet]. StatPearls Publishing.(Assessing and Diagnosing Patients with Anxiety Disorders Comprehensive Nursing Paper Sample)

https://www.ncbi.nlm.nih.gov/