Week 4 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 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), 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.
From the video
CC: “Fiancé suggested that I make an appointment. “
“3 nights ago went to a county fair with wife’s sister
and her husband. Fireworks started to go off no warning, big Skyfall
explosions, I took off running trying to find cover.” ‘it scared the … out of
me.” 2 cops saw me running and thought I pickpocketed someone, they took me
down tried to calf me, then I yelled I’m a combat veteran. They helped me to my
feet gave me cold water, was shaking and they helped me.
Explosions are a trigger and other Loud noises. “last
week, a car back fired and I jumped behind a magazine rack.”
Smells set him off, “diesel fuel”, Charlie a neighbor
was grilling, had hair in arm burn, no injuries, the smell set him off.
What came to mind? “2 of my buddies they got burned
when their home was blown and it smelled…….”
Memories are way too strong.
Dreams every night about the events, “makes me want to
crawl in bed and close my eyes.”
Has nightmares, and startle easily,
Traffic makes him anxious, in traffic lights with
people all over,” break out in sweat, start shaking and can’t catch breath.
Other
difficulties:
Sometimes fiancé argues with her mother, never
mattered, “now I can’t handle it. Any negative situation. I want to crawl into
a whole and hide.”
Feels “I’m a coward, I’m a wimp.”
“I don’t want to go anywhere, out to restaurants,
shopping, or even baseball pubs, I stay in my room all day, afraid to sleep,
it’s bad.”
Complete and submit your Comprehensive Psychiatric Evaluation,
including your differential diagnosis and critical-thinking process to
formulate primary diagnosis.
Incorporate the following into your responses in the template:
·
Subjective: What details did the patient provide regarding
their chief complaint and symptomology to derive your differential diagnosis?
What is the duration and severity of their symptoms? How are their symptoms
impacting their functioning in life?
·
Objective: What observations did you make during the
psychiatric assessment?
·
Assessment: Discuss the patient’s mental status
examination results. What were your differential diagnoses? Provide a minimum of three possible
diagnoses with supporting evidence, listed in order from highest priority to
lowest priority. Compare the DSM-5-TR diagnostic criteria for each
differential diagnosis and explain what DSM-5-TR criteria rules out the
differential diagnosis to find an accurate diagnosis. Explain the critical-thinking
process that led you to the primary diagnosis you selected. Include pertinent
positives and pertinent negatives for the specific patient case.
·
Reflection
notes: What would you
do differently with this client if you could conduct the session over? Also
include in your reflection a discussion related to legal/ethical considerations
(demonstrate critical thinking beyond confidentiality and consent for
treatment!), 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.).
