Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
Objective: What observations did you make during the interview and review of systems?
Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why?
Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.
CASE STUDY
JT is a 50 year old male and a veteran. He retired from military two years ago due to poor eye sight. He was deployed to Iraq 6yrs, Afghanistan 2yrs before he finally retired. But since then he is unable to function because he has bad anxiety. He has been unable to sleep peacefully because of nightmares that keeps coming. He said he feels like he left the war but the war never left him. He is unable to go out because he is afraid of crowd yet scared when he is left alone, it makes him feel unsafe. He sweats and shivers when he is in the public. He expresses having a hard time staying focused on completing tasks properly and in a timely manner, especially when he is given multiple tasks to do at a given time. These symptoms began 5yrs ago and have affected his ability to function at work and at home. According to the patient, there have not been any symptom-free periods since their onset. In the past, he has been prescribed Clonazepam 1 mg twice daily after being diagnosed with anxiety disorder. He has not received individual or group psychotherapy for his symptoms in the past, nor has he been hospitalized as a result of these symptoms. He does not have a history of self harm, suicidal thoughts, or suicidal attempts, and he is not currently taking any medications for his symptoms. The patient eats 2-3 meals a day, and usually struggles to fall asleep. He exercises regularly, about 3 times a week, and does not have a history of alcohol or substance abuse.