Psychiatric Assessment and Differential Diagnosis: A Case of PTSD, Major Depressive Disorder, and Schizophrenia
Instructions
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): “ The government are watching me with the drone without my consent”
HPI: J.A is a 43 year old African American who was recently discharged from the hospital due to agreession, threatening to shoot his neighbor, suicide attempt by cutting his wrist,visual and auditory hallucination. He mentioned that his neighbor works for the government and they always watch him with drone. He was at the hospital for 13 days and was on medication the whole time. He was referred by the doctor to seek psychiatric help after hospital discharge.
According to his older sister, he has not been the same since he came back from his last military tour 8 months ago, but has not had any fight with the neigbors until the recent time. He sometimes has some road rage, but she never know it was an effect from his military time. During the assessment, he mentioned that he been having some flashbacks and is triggered by smell of a burning flames,bbq, traffic, or loud noice. He barely get out of the house due to fear of being monitored.
He rates his depression on the scale of 1-10 ( 10 being the worst), he rated it to 7/10), anxiety 6/10. He drinks occasionally and smoke marijuana to help him cope or sleep. He was seeing a psychotherapist for depression and PTSD, but was not on medication before his recent hospital admission. He has good appetite. He sleeps about 3 to 4 hours at night due to nightmares, but sometime take benedryl to help him sleep.
Substance Current Use: Alcohol, Marijuana. Denies any other illicit drug use
Past psychiatric history: PTSD, depression
Medication trials and current medications: Respiradone 2 mg daily, Zoloft 50 mg daily, Celexa 10 mg daily, Lisinopril 10 mg daily, Atorvastatin 40 mg at bedtime.
Psychotherapy or previous psychiatric diagnosis: He has being seeing the psychotherapist for the past 3 months.
Family psychiatric history: No family history of mental health problems, suicide, or unknown death before 30 years old.
Medical History: HTN, HLD
- Allergies: PCN
Reproductive Hx: He has two daughter from his ex-wife. He is sexually active, but not in any relationship.
Psychosocial: Patient was born and raise in Houston Texas, but moved down to East Texas After his high school. He has two younger brother and one older sister. He is currently staying with his sister. Both parent died years ago and he is in good relationship with his siblings. He was married for 14 year with 2 daughters, but divorced 2 years ago. He has a highschool depplmawith some college classes.
He joined the military while in college. He has an emotional trauma from when he was in Afghanistan. One of his friend was burn when they were in a convoy with a grenade. He has a legal issue with the law after he tried to kill his neigbhor. No physical or head trauma. He used to enjoy going to football game with his brothers, and also like to ride motocycle with his friends.
ROS:
- GENERAL: Negative fever, chills or weknessess.
- HEENT: Patient denied any head trauma, Eyes: No eyes pains, or discharges. Ear:No congestion, or ear ache. Nose: No sinus, or rhinorrhea reported. Throat: No sore throat, or dysphagia.
- SKIN: Denies skin burn or rashes
- CARDIOVASCULAR: No hart murmur, tachycardia or any chest pain
- RESPIRATORY: Denies difficulty breathing or frequent coughing.
- GASTROINTESTINAL: No abdominal discomfort, constipation or N/V
- GENITOURINARY: No painful urination, or blood in the urine. Denies flank pain or unpleasant uring odor.
- NEUROLOGICAL: No headaches or dizziness
- MUSCULOSKELETAL: No muscle weakness or broken bone.
- HEMATOLOGIC: No bleeding or anemia reported.
- LYMPHATICS: No enlarged lyph nodes reported
- ENDOCRINOLOGIC: Denies heat or hot intolerance.
- PSYCHIATRIC: Reports nightmares, hallucination and depression.
Objective:
Diagnostic results: N/A
Assessment:
Mental Status Examination: Patient is a 43 yea old African American who stated that he has feeling that people are watching him and and he threatened to shoot his neighbor. He confirmed he has been having hallucination of people talking to him through the TV and he sometimes see a movement with the corner of his eyes. He was akert and oriented the whole time and was cooperative during the assessment. He was a good reliable historian with no developmental discorder. He denied any suicidal attempts, but had some thoughts to hurt his neigbhor.
- Diagnostic Impression: Diagnosis/Diagnoses – include all mental health diagnoses and the ICD-10 codes for each. Be Specific with diagnosis. Example: Major depressive disorder, recurrent, moderate F33.1; General anxiety disorder F41.1
- At least three differentials with supporting evidence. List them from top priority to least priority.
- PTSD
- MAJOR DEPRESSIVE DISORDER
- SCHIZOPHRENIA
Reflections: Discuss what you learned and what you might do differently. Include a brief rationale for your treatment plan. You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differential diagnoses and treatment plan. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rule out the differential diagnosis to find an accurate diagnosis.
Explain the critical-thinking process that led you to the primary diagnosis you selected. (Hint: the documentation in subjective and objective should support your diagnosis according to DSM-V!) Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Case Formulation and Treatment Plan:
Already did, just add a citation reference to it.
Continue the medication from the hospital and add Prazosin 2 mg at bedtime for nightmare.
Continue with pscychotherapy with the therapist
Get routine labs
Take medication as ordered
Get involve with some social activites.
Avoid marijuana use, take medication as prescribed an watch for side effects. Also to avoid stoping the medication abruptly.
Follow up in 4 weeks, but call the hotline for any emergency.
DON’T DO THIS
References
- Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
Solution
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): “ The government are watching me with the drone without my consent”
HPI: J. A is a 43-year-old African American who was recently discharged from the hospital due to aggression, threatening to shoot his neighbor, a suicide attempt by cutting his wrist, and visual and auditory hallucinations. He mentioned that his neighbor works for the government and they always watch him with a drone. He was at the hospital for 13 days and was on medication the whole time. He was referred by the doctor to seek psychiatric help after hospital discharge. According to his older sister, he has not been the same since he came back from his last military tour 8 months ago but has not had any fights with the neighbors until recent time.
He sometimes has some road rage, but she never know it was an effect of his military time. During the assessment, he mentioned that he has been having some flashbacks and is triggered by the smell of burning flames, bbq, traffic, or loud noise. He barely gets out of the house due to fear of being monitored. He rates his depression on a scale of 1-10 ( 10 being the worst), he rated it to 7/10), and anxiety 6/10. He drinks occasionally and smokes marijuana to help him cope or sleep. He was seeing a psychotherapist for depression and PTSD but was not on medication before his recent hospital admission. He has a good appetite. He sleeps about 3 to 4 hours at night due to nightmares but sometimes takes Benedryl to help him sleep.
Substance Current Use: Alcohol, Marijuana. Denies any other illicit drug use
Past psychiatric history: PTSD, depression
Medication trials and current medications: Respiradone 2 mg daily, Zoloft 50 mg daily, Celexa 10 mg daily, Lisinopril 10 mg daily, Atorvastatin 40 mg at bedtime.
Psychotherapy or previous psychiatric diagnosis: He has been seeing the psychotherapist for the past 3 months.
Family psychiatric history: No family history of mental health problems, suicide, or unknown death before 30 years old.
Medical History: HTN, HLD
Allergies: PCN
Reproductive Hx: He has two daughters from his ex-wife. He is sexually active, but not in any relationship.
Psychosocial: The patient was born and raised in Houston Texas, but moved down to East Texas After high school. He has two younger brothers and one older sister. He is currently staying with his sister. Both parents died years ago and he is in a good relationship with his siblings. He was married for 14 years with 2 daughters but divorced 2 years ago.
He has a high school diploma with some college classes. He joined the military while in college. He has emotional trauma from when he was in Afghanistan. One of his friends was burnt when they were in a convoy with a grenade. He has a legal issue with the law after he tried to kill his neighbor. No physical or head trauma. He used to enjoy going to football games with his brothers, and also like to ride a motorcycle with his friends.
ROS:
Objective:
- GENERAL: Negative fever, chills, or weaknesses.
- HEENT: Patient denied any head trauma, Eyes: No eye pains, or discharges. Ear: No congestion, or earache. Nose: No sinus or rhinorrhea reported. Throat: No sore throat, or dysphagia.
- SKIN: Denies skin burn or rashes
- CARDIOVASCULAR: No heart murmur, tachycardia, or any chest pain
- RESPIRATORY: Denies difficulty breathing or frequent coughing.
- GASTROINTESTINAL: No abdominal discomfort, constipation or N/V
- GENITOURINARY: No painful urination, or blood in the urine. Denies flank pain or unpleasant urine odor.
- NEUROLOGICAL: No headaches or dizziness
- MUSCULOSKELETAL: No muscle weakness or broken bone.
- HEMATOLOGIC: No bleeding or anemia reported.
- LYMPHATICS: No enlarged lymph nodes were reported
- ENDOCRINOLOGIC: Denies heat or hot intolerance.
- PSYCHIATRIC: Reports nightmares, hallucinations, and depression.
Diagnostic results: N/A
Diagnostic results: N/A
Assessment:
Mental Status Examination: Mental Status Examination: The patient is a 43-year-old African American who stated that he has feelings that people are watching him and he threatened to shoot his neighbor. He confirmed he has been having a hallucination of people talking to him through the TV and he sometimes see a movement from the corner of his eyes. He was alert and oriented the whole time and was cooperative during the assessment. He was a good reliable historian with no developmental disorder. He denied any suicidal attempts but had some thoughts to hurt his neighbor.
Differential Diagnoses
The three differential diagnoses identified are post traumatic stress disorder, major depressive disorder and schizophrenia.
Post Traumatic Stress Disorder (F43.12)
The first differential diagnosis for the patient based on the clinical manifestation and history is a post-traumatic stress disorder. Post-traumatic stress disorder is a mental illness that affects individuals that have gone through traumatic experiences such as sexual violence, exposure to death or threat to death, or even repeated exposure to aversive details such as combat experience (Muller et al., 2017).
The patient should have the presence of intrusion symptoms such as involuntary memories of the event, avoidance symptoms such as avoiding external reminders like people activities, etc, or even thoughts, negative alterations in cognitions and moods, and alterations in arousal and reactions associated with the traumatic events. The patient’s psychosocial history indicates that he experienced a traumatic event in Afghanistan when his friend was burnt by a grenade when they were in a convoy. More so, he gets triggered by the smell of smoke and even barbeque. The above details support PTSD as the priority diagnosis for the patient.
Major Depressive Disorder (F33.1)
The second differential diagnosis is major depressive disorder (MDD). The DSM-5 criterion for the diagnosis of MDD includes a patient presenting with complaints of a depressed mood, low moods, feelings of hopelessness, loss of interest in activities that one derived pleasure from, lack of energy, poor concentration, changes in appetite, sleep disturbances, feelings of hopelessness, suicidal thoughts as well as psychomotor retardation (American Psychiatric Association, 2013; Hasin et al., 2018). Based on the patient’s history, the patient rates his depression 7/10, sleeps for approximately3 4 hours, and has been using marijuana and alcohol to help him sleep. More so, he had threatened suicide by cutting his wrist, showed signs of aggression, and even threatened to shoot his neighbor.
Schizophrenia (F20.9)
Schizophrenia is the third diagnosis. Schizophrenia is a mental illness that is characterized by an array of signs and symptoms such as delusions, hallucinations, abnormal motor behavior, and disorganized thinking (Nuno et al., 2019). Patients suffering from schizophrenia tend to suffer diverse impairments and limitations in different areas of functioning like work, interpersonal relations, self-care, and education. The patient has been having delusions such as believing that the government has been watching him using a drone without consent. He also has been hallucinating about people talking to him through the television.
Reflections:
Based on the patient’s history of delusions, I would try to establish a therapist-patient relationship to create trust and enable him to feel safe in the hospital setting. I would similarly show empathy and understanding of his situation. The patient diagnosis process was based on the patient’s medical history, clinical manifestation, and patient data. The above information enabled me to rule out diagnoses while coming up with the three priority diagnoses with the priority one being post-traumatic stress disorder, followed by major depressive disorder and schizophrenia.
Some of the ethical and legal issues that would affect the patient’s case include the patient’s history of threatening to kill the neighbor, as well as a history of alcohol and marijuana use. The threat to kill someone would result in legal issues with the authorities. On the other hand, the use of ethical and marijuana is likely to aggravate the situation such as worsening the aggression and anxiety levels, resulting in strained relationships with others in the community and family members while most importantly could result in adverse events emanating from interactions with some of the medication that he is using to manage his symptoms.
Case Formulation and Treatment Plan:
Continue the medication from the hospital and add Prazosin 2 mg at bedtime for a nightmare.
Continue with psychotherapy with the therapist
Get routine labs
Take medication as ordered
Get involved with some social activities.
Avoid marijuana use, take medication as prescribed, and watch for side effects. Also to avoid stopping the medication abruptly (Guy et al., 2020).
Follow up in 4 weeks, but call the hotline for any emergency.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Guy, A., Brown, M., Lewis, S., & Horowitz, M. (2020). The ‘patient voice’: patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition. Therapeutic Advances in Psychopharmacology, 10, 2045125320967183.
Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA psychiatry, 75(4), 336-346.
Müller, J., Ganeshamoorthy, S., & Myers, J. (2017). Risk factors associated with posttraumatic stress disorder in US veterans: A cohort study. PloS one, 12(7), e0181647.
Nuño, L., Guilera, G., Coenen, M., Rojo, E., Gómez-Benito, J., & Barrios, M. (2019). Functioning in schizophrenia from the perspective of psychologists: A worldwide study. PloS one, 14(6), e0217936.