Subjective
CC (chief complaint): The patient interviewed on the military base. The woman expressed that people around her are concerned that she has PTSD.
HPI: R. C. is a 25 years old female. At the time of visit she lived off-base in El Paso, Texas, active duty in the Army, presents for concerns for PTSD. The patient has troubles sleeping after experiencing a traumatic event in Iraq. The eating behavior is also inconstant, as patient’s weight fluctuates. R. C. suffers from constant crying spells until having no energy to cry any longer. Feels guilt, low energy and low interest in regular activities such as playing with her cat. The sex drive is absent. Thinks that it would not matter if her life was gone.
According to DSM-5-TR criteria for PTSD, the patient experiences intrusive thoughts, avoidance of people, places, and social situations, pervasive negative emotional state in form of shame, and guilt, and has difficulties sleeping. Does not take any substances that would have an effect on the symptoms, and does not have other mental health diagnosis. In order to be diagnosed with the PTSD, one must:
- encounter a traumatic event – check;
- have at least one intrusive symptom – daydreaming of things that happened in Iraq;
- have at least one symptom of avoidance – does not want to be spoken to in stores;
- have at least two symptoms of negative changes in feelings and mood – experiences crying spells, has no energy to even pay with her cat;
- have two or more changes in arousal and reactivity – the patient lost her sex drive, does not enjoy the activities that she used to like a lot (Miao et al., 2018).
Past Psychiatric History
General Statement: The patient entered treatment for depression at the age of 13 or 14, later started experiencing its symptoms after stopping taking antidepressants at the age of 18.
Caregivers are listed if applicable.
Hospitalizations:No hospitalizations. No residential treatments. No suicidal or homicidal behaviors or self-harm.
Medication trials: Cipro previous medication trials: sertraline, fluoxetine both with good effects when taking.
Psychotherapy or Previous Psychiatric Diagnosis: The patient was prescribed antidepressants, which had a positive effect on depression symptoms.
Substance Use History
No substance use history
Family Psychiatric/Substance Use History
Pateint’s mother was diagnosed with depression; brother has history of cannabis use.
Psychosocial History: At the time of visit she lived off-base in El Paso, Texas, active duty in the Army, MOS 92M Mortuary Affairs Specialist. Spent her childhood in McAllen TX in a family of mother, father, and one brother. Completed education through high school. Currently partnered with Luke who also serves the army and works as a driver. No children. Did not refer to any of childhood trauma, recalls being depressed in the age 13-14.
Medical History: No medical history.
Current Medications: Does not take any medications currently.
Allergies: Has allergies, need to clarify
Reproductive Hx: The patient claims that she feels worse during her period. Does not have sex drive, but agrees to do it, when her partner presses doing something of sexual nature.
ROS
- GENERAL: Weight might fluctuate due to irregular eating behavior. Other than that no fever, chills, weakness, or fatigue.
- HEENT: Eyes: No 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: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
- RESPIRATORY: No shortness of breath.
- GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
- GENITOURINARY: No Burning on urination, urgency, hesitancy, odor, odd color
- NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
- MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
- HEMATOLOGIC: No anemia, bleeding, or bruising.
- LYMPHATICS: No enlarged nodes. No history of splenectomy.
- ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Objective
Physical exam: Physical exams are not needed for diagnosis of PTSD. However, to rule out differential diagnoses, CT and MRI screens are necessary. The results of such examinations will determine whether the patient has serious brain injuries. In addition, levels of Calcium and Vitamin D should be checked to rule out its deficiency.
Diagnostic results: In case MRI and CT scans show no signs of serious brain illnesses such tumors, and levels of Calcium and Vitamin D are within the norm, then the diagnosis PTSD can be made.
Assessment
Mental Status Examination: R. C. is a 25 years old female, who presented well-organized and groomed. The answers were precise, but when the topic touched personal matters, the patient replied with some hesitation. Despite having a military profession, the voice lacked energy and enthusiasm, which is a sign of loss of energy overall. The thought process of the patient was logical, and goal directed, the patient never replied with “I don’t know”. In addition, the question about suicidal though was answered with the awareness of one’s Baptist upbringing, which is a sign of continuous self-awareness. Homicidal behaviors are denied, but the patient does not see value in the fact that she lives. No sign of auditory or visual hallucinations, but when asked about reaction to loud noises, the patient mentioned that did not hear a loud thump at night, which concerned her boyfriend. The concentration levels are good. The recent and remote memory of the patient is intact as she does not recall any losses of memory. However, the patient finds it hard to focus when reading, claiming that she has to reread the page again to understand what is written there (Miao et al., 2018). This can be attributed to the intrusive thoughts that are common for post-traumatic stress disorder.
Differential Diagnoses: One of the differential diagnoses is depression (major depressive disorder). The patient experiences loss of energy, fatigue. Changes in weight without dieting associated with sudden loss or gain of appetite. Being in a depressed mood nearly every day. Loss of interest in daily pleasure and activities that used to bring joy. The patient also lost the ability to concentrate on things she reads or watches. The history of taking antidepressants and recalling feeling better along with feeling unreasonable guilt for little things that she cannot control. Finally, despite rejecting suicidal thoughts, the patient confirms that she thinks that it would not matter if her life was gone. All of these criteria match the DSM-5 diagnostic criteria for depression (Otte et al., 2016). However, lack of suicidal ideation and reduction of physical movement rule out that diagnosis.
The second differential diagnosis is bipolar I disorder, which is characterized by the lack of psychotic episodes. The symptoms described by the patient match the depressive phase of the disorder (McIntyre et al., 2020). However, the diagnosis should be ruled out as the patient does not have any of the symptoms of manic episodes.
The third differential diagnosis is persistent depressive disorder (DSM-V) or dysthymic disorder (DSM-IV) (Ogasawara et al., 2018). While the date of the traumatic event is not determined, the symptoms of the depressive disorder are present for a long time. To be diagnosed with persistent depressive disorder, one must experience depressed mood for the period of more than two years (Uher et al., 2014). In case of R. C., the symptoms are experienced since she was 18. However, the diagnosis should be ruled out because it does not into account the traumatic event that had added several new symptoms.
Reflections: Overall, the assessment provided in this case requires more details and information. As such, the date of traumatic even, and the severity of symptoms is often left unaddressed or described vaguely. During the interview it is important to address every aspect of the potential diagnosis for more precise results. However, working with depressive mood disorders and post-traumatic stress is ethically sensitive. Therefore, healthcare providers should be aware of socioeconomic factors and cultural background of the patient to obtain the information ethically. While working with veterans and army servants, doctors must understand the specifics of realities of war, and try to keep the patient from overindulging in these memories. Therefore, healthcare providers must control the conversation to ensure effective assessment.
References
McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A. Vieta, E., Vinberg, M., Young, A. H. & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841-1856.
Miao, X. R., Chen, Q. B., Wei, K., Tao, K. M., & Lu, Z. J. (2018). Posttraumatic stress disorder: from diagnosis to prevention. Military Medical Research, 5(1), 1-7.
Ogasawara, K., Nakamura, Y., Kimura, H., Aleksic, B., & Ozaki, N. (2018). Issues on the diagnosis and etiopathogenesis of mood disorders: reconsidering DSM-5. Journal of Neural Transmission, 125(2), 211-222.
Otte, C., Gold, S. M., Penninx, B. W., Pariante, C. M., Etkin, A., Fava, M., Mohr, D. C. & Schatzberg, A. F. (2016). Major depressive disorder. Nature Reviews Disease Primers, 2(1), 1-20.
Uher, R., Payne, J. L., Pavlova, B., & Perlis, R. H. (2014). Major depressive disorder in DSM‐5: Implications for clinical practice and research of changes from DSM‐IV. Depression and anxiety, 31(6), 459-471.