CC (chief complaint): Berry Sullivan complains that he suffers from post-traumatic stress disorder after the war.
HPI: Sergeant’s post-traumatic syndrome occurred on his return from a military action zone. At first it manifested itself in the fact that he reacted sharply to the sounds of salutes or the smell of burning hair (Symptom Media, 2016). This is explained by the fact that they caused him painful memories. Afterwards, Sergeant’s post-traumatic syndrome progressed and he felt apathy toward the events surrounding him.
Past Psychiatric History:
- General Statement: The man suffers from post-traumatic stress disorder.
- Caregivers (if applicable): No applicable.
- Hospitalizations: There was no hospitalization.
- Medication trials: No applicable.
- Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric treatment or diagnosis.
Substance Current Use and History: He does not suffer from any kind of addiction and has not been treated.
Family Psychiatric/Substance Use History: The sergeant does not mention his mother, but indicates that his father suffered from alcohol addiction. Also, the father has a secondary condition that is common to people who abuse alcohol, which is high blood pressure and cirrhosis (Symptom Media, 2016). In addition, the patient mentioned that his grandfather was also in the military and suffered from depression due to his association with the military and combat.
Psychosocial History: Only the sergeant’s father had alcohol abuse problems in the family, which influenced the sergeant to not abuse drugs or alcohol.
Medical History:
- Current Medications: He is not taking any medication now.
- Allergies: Seasonal allergies.
- Reproductive Hx: Berry Sullivan is engaged and plans to have children in the future.
ROS:
- GENERAL:
- HEENT: Sleep disorder.
- SKIN:
- CARDIOVASCULAR: Rapid heartbeat.
- RESPIRATORY: Service-connected asthma; difficult breathing and gasping.
- GASTROINTESTINAL: Nausea.
- GENITOURINARY:
- NEUROLOGICAL:
- MUSCULOSKELETAL:
- HEMATOLOGIC:
- LYMPHATICS:
- ENDOCRINOLOGIC:
Objective:
- Physical exam: if applicable
- Diagnostic results: No applicable.
Assessment:
- Mental Status Examination: It is significant to notice, that the post-traumatic stress disorder is a disturbance of work of mentality as a result of an encounter with the traumatic factor (Shalev et al., 2017). In the sergeant’s case, that factor was participation in combat and the loss of friends and acquaintances in combat. Accordingly, he has received a strong experience, which is outside of the bounds of usual experience and causes an extreme overstrain of the entire emotional-volitional sphere of a person. Consequently, certain sounds or smells trigger intrusive disturbing memories that are unusually vivid but detached in nature. In those moments Berry Sullivan experiences fear and subconsciously tries to protect himself, for example, falling down during fireworks, because they remind him of gunfire. In addition, a symptom of PTSD are recurrent disturbing dreams, nightmares about the tragic event in that the man suffers from insomnia (Shalev et al., 2017). Physical manifestations of the illness that are evident in the sergeant also include irregular breathing, nausea and rapid heartbeat. Therefore, he suffers from post-traumatic stress disorder resulting from a traumatic combat experience.
- Differential Diagnoses: It is incorrect for a man to be diagnosed with generalized anxiety disorder. That is because it is a mental condition characterized by widespread and persistent anxiety and tension that is not justified by the life situation and inadequate to the circumstances (Goodwin et al., 2017). In this way, the symptoms of this disorder are identical to those of Sargeant. Accordingly, not knowing the man’s history of participation in military activities can lead to an incorrect diagnosis of this condition.
- Reflections: Therefore, Berry Sullivan suffers from post-traumatic stress disorder. This is manifested in the fact that after returning from combat a man who does not have significant illnesses and does not abuse alcohol and drugs has health problems. The vivid symptoms of the disorder appear when he hears sounds or smells that remind him of shots, death or blood. In addition, at this moment there is a protective reaction of the body such as nausea and the desire to hide from it (Shalev et al., 2017). Furthermore, sleep problems and shortness of breath when recalling events that occurred during the war indicate the presence of post-traumatic stress disorder, not another illness.
References
Goodwin, H., Yiend, J., & Hirsch, C. R. (2017). Generalized anxiety Ddsorder, worry and attention to threat: A systematic review. Clinical Psychology Review, 54, 107-122. Web.
Shalev, A., Liberzon, I., & Marmar, C. (2017). Post-traumatic stress disorder. New England Journal of Medicine, 376(25), 2459-2469. Web.
Symptom Media. (2016). Training title 21 [Video]. Web.