DRNP6635 Week 3 Assignment – Assessing and Diagnosing Patients with Mood Disorders

(Training Title 18)SUBJECTIVE:
CC (chief complaint): “Everyone keeps saying I have PTSD. Even Luke says I have it.”
HPI (history of present illness): The patient is a young Black female adult (probably in her
mid-to-late 20s) who presents to the clinic for a psychiatric assessment. She is currently serving
in the US Army “base” and lives with her boyfriend Luke “off base.” She reports being
repeatedly reminded that she has PTSD. She admits being “depressed” at thirteen and fourteen,
although she was treated with antidepressants but stopped taking them at eighteen when she
decided to join the Army. She has also been depressed excessively since eighteen and the
depression worsens during her period. She also reports feeling “sad” when she remembers
loading body bags into planes in Iraq. She does not sleep well; she tosses and turns throughout
the night, often thinking about her escapades in Iraq, especially the kids over there who had burn
scars and others missing hands and legs because of the mines. She also reports a fluctuating
appetite; sometimes eating “three big meals and snacking all day.” Her weight has also been
shifting up and down like a roller coaster. She also acknowledges lacking concentration,
experiencing prolonged crying spells, feeling more guilty than most people, lacking sex drive,
having low energy and being disinterested in other activities, and feeling anxious and less
confident about herself. She cannot remember information after reading a page in a magazine
over and over, cannot stop crying, feels she disappointed her parents and sister while in school,
only gives in to Luke’s sexual interests upon persuasion, and dislikes her past hobbies, including
going shopping and playing with her cat. However, she denies nightmares, startling behaviors,
and suicidal ideations because she was raised in a Baptist church.
Past Psychiatric History and Diagnosis: The patient reports being diagnosed with PTSD at
thirteen and fourteen. She was treated using antidepressants but stopped taking them at eighteen

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after expressing interest to enlist in the Army. Her depression deteriorated at eighteen after
stopping the medications; it gets worse during her periods. She always feels “sad” about her
experiences in Iraq, especially when she remembers loading body baps into the plane.
Substance Current Use: She denies smoking or using alcohol and other drugs, such as
cannabis, cocaine, and prescription drugs.
Social History: The patient works on base but lives “off base” with her boyfriend Luke. She
reports lacking someone to talk to because his boyfriend is a driver and is always away most of
the week. Luke is a former soldier and the two met while serving in the Army together.
Medical History:
The patient has had no major surgeries, procedures, and hospitalizations.
 Medication Trials and Current Medications: She was using antidepressants since aged
thirteen and fourteen but stopped at eighteen. She is currently not using any drugs or
traditional therapies.
 Allergies: No known food, seasonal, drug, animal, and environmental allergies.
 Reproduction Hx: She is sexually active and currently in a sexual relationship with her
boyfriend Luke. However, she reports being disinterested in sexual activities most of the
time.
ROS (Review of Systems):
General: She reports experiencing a fluctuating appetite. Her weight also shifts up and
down like a roller coaster.
HEENT: Head: The patient denies suffering from any head injuries recently. Eyes: She
denies yellow sclerae, visual loss, or double/blurred vision. Ears, Nose, & Throat: No ear

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discharge, ear pain, or hearing loss. She also denes sore throat, sneezing, runny nose, or
congestion.
Skin: Negative for skin rashes, wrinkling, itches, or patches.
Respiratory: She denies coughing, producing sputum, sneezing, wheezing, and SOB
(shortness of breath).
Cardiovascular: She denies a history of irregular heartbeats or palpitations, edema,
fatigue, or chest pain/pressure/discomfort.
Gastrointestinal: She reports unintentional changes in appetite and weight. However,
she denies abdominal pain, bowel habit changes, vomiting, nausea, anorexia, heartburn,
or dysphagia.
Genitourinary: She reports low sex drive (low libido). She denies urination hesitancy
(difficulty initiating urination), urgency (a strong and abrupt urination urge), frequency
(needing to urinate more often than normal), dysuria, hematuria, and incontinence. She
also denies genital discharge.
Neurological: The patient is oriented and alert. She denies ataxia, paralysis, dizziness,
headaches, seizures, tingling/numbness, muscle weakness, speech and coordination
problems, visual changes, and syncope or loss of consciousness. However, she reports
sleep disturbances, difficulty concentrating, and forgetfulness. She also reports feeling
anxious, sad, and depressed.
Musculoskeletal: She denies gait abnormalities, back pain, fractures, deformities, muscle
cramps/weakness, and joint soreness/stiffness/pain.
Hematologic: She denies fatigue, excessive bleeding/bruising, ecchymosis,
splenomegaly, and lymphadenopathy.

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Lymphatic: She denies lymph node tenderness, splenectomy, or swollen lymph nodes.
Endocrinologic: She denies night sweats, cold/heat intolerance, fever, polyuria,
menstrual irregularities, or fatigue.
OBJECTIVE:
Physical Exam
Gastrointestinal: The patient has an abnormal appetite.
Neurological: She experiences sleep disturbances, difficulty concentrating, and
forgetfulness or memory issues. She does not sleep properly, but when she does, she
tosses and turns throughout the night flashing back at kids she witnessed suffering in
Iraq. She cannot concentrate or remember information read a few minutes or hours ago.
She also reports often feeling guilty, anxious, sad, and depressed. She blames herself a
lot; she feels she has disappointed her parents, sister, comrades, and boyfriend, Luke.
Endocrinologic: She has low energy and dislikes doing things she liked before, such as
going to shop. She also has low libido or sex drive.
Diagnosis Results:
 Complete blood count (CBC) to evaluate the patient’s general wellbeing and potentially
rule out underlying conditions, such as bacterial/viral infections or anemia
 Thyroid function tests to measure T4, T3, and TSH levels to rule out hypothyroidism, a
disease that often causes symptoms/signs similar to PTSD
 Liver function tests and kidney function tests to rule out underlying factors, including
endocrinologic diseases causing weight changes and loss of appetite
 Urinalysis to rule out UTIs
ASSESSMENT:

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Mental Status Examination:
The patient is oriented to person, time, and place. She is neatly dressed in Army uniform and
demonstrates high energy. Her speech is clear, coherent, and articulate. She responds to questions
appropriately and correctly. Her face appears sad and gloomy. She sometimes stares into space
and appears disturbed or distracted by other thoughts outside the interview. She reports feeling
extremely “sad” and “depressed” since turning eighteen; the situation worsens during periods.
She reports experiencing sleeping disturbances at night and poor concentration and memory.
Some days, she cries a lot until she has no more energy left. The patient also exhibits extreme
levels of “guilt.” She blames herself a lot and feels she disappointed everyone in her life, from
her parents and sister to her comrades and boyfriend. She lacks the energy and interest in
activities. She also gets anxious and less confident about herself and feels “not good enough.”
She denies suicidal ideations, nightmares, and startling reaction to loud sounds or any other
unexpected, sudden stimulus.
Differential Diagnosis/Diagnostic Impression:
 Posttraumatic Stress Disorder (PTSD)
The primary diagnosis for the patient is PTSD. The DSM-5-TR diagnostic criteria for
PTSD requires that the patient must meet the following five criteria: (1) exposure to the
stressful or traumatic event, (2) experience at least one “intrusion” symptom, (3) exhibit
at least one “avoidance” symptom,
 Acute Stress Disorder (ASD)

 Major Depressive Disorder (MDD)

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Reflection: