NRNP 6635 Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD

Subjective:

CC (chief complaint): “I fear telling others about my sexuality”

HPI: the patient is Mr. Ralph Newsome, a 19-year-old male that came to the psychiatric clinic for psychiatric assessment. The patient is a former military personnel and currently works part time in construction. The patient reports difficulties in telling others about his sexuality. The patient reports that he has been weighing about the benefits and disadvantages of revealing his sexuality as a gay. He fears the ridicule that he would experience from other soldiers after knowing about his sexuality. The patient reports that he has never told anyone about his sexuality, except the psychiatrist. The patient reports that he fears that others will not be comfortable being around him after he tells them his sexuality. The patient denies sexual thoughts about men but reports interest in close relationship with them as well as women. He also acknowledges fear of rejection from others following his disclosure. He reports suicidal thoughts when he was young but denies any recent thoughts, plans, or intention.

Past Psychiatric History: The patient denied any history of psychiatric illnesses

General Statement: I fear telling others about my sexuality
Caregivers (if applicable):none
Hospitalizations: the client denies any history of hospitalization
Medication trials: The client denies any history of medication trials
Psychotherapy or Previous Psychiatric Diagnosis: The client denies any history of psychotherapy or previous psychiatric diagnosis

Substance Current Use and History: The client denies any current or previous use of alcohol, smoking, and other substance use or abuse

Family Psychiatric/Substance Use History: The client denies any history of psychiatric or substance abuse history in the family

Psychosocial History: The client lives alone with his dog. He is the only child in his family. He currently works part time in construction. He has been recalled to Iraq to work as a soldier. The patient reports that his family is his source of social support. He denies any stress. However, he fears telling others about his sexuality.

Medical History: The patient denied any history of hospitalization or surgeries.

Current Medications: The patient is not currently using an medications.
Allergies:The patient reported that he is allergic to Penicillin. He denied food and environmental allergies.
Reproductive Hx:The patient is single. He is not in a relationship. He denies dysuria, frequency and urgency. He also denies any history of sexually transmitted infections or abuse.

ROS:

GENERAL: The patient is dressed appropriately for the occasion. There is no evidence of weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: The patient denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: He also denies hearing loss, sneezing, congestion, runny nose, or sore throat.

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SKIN: The patient denies rash or itching.

CARDIOVASCULAR: The patient denies chest pain, chest pressure, or chest discomfort. He also denies palpitations or edema.

RESPIRATORY: The patient denies shortness of breath, cough, or sputum.

GASTROINTESTINAL: The patient denies anorexia, nausea, vomiting, or diarrhea. He also denies abdominal pain or blood.

GENITOURINARY: The patient denies burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: The patient denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. He also denies change in bowel or bladder control.

MUSCULOSKELETAL: The patient denies muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: The patient denies anemia, bleeding, or bruising.

LYMPHATICS: The patient denies enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: The patient denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective:

Physical exam:

Vital signs: BP 119/76 P 68 T 36.7 SPO2 98% at room air, RR 20 beats per minute, regular

Respiratory: Presence of clear lung sounds and absence of wheezing, cough, and nasal flaring.

Cardiovascular: Presence of S1 and S2 heart sounds. Absence of adventitious heart sounds and body edema.

Diagnostic results: None

Assessment:

Mental Status Examination: The patient is dressed appropriately for the occasion. He appears of the appropriate weight for his age and gender. He denies fever, fatigue, or chills. The patient is alert and oriented to self, others, time, and events. The thought process is intact and future oriented. The patient maintains normal eye contact during the assessment. He demonstrates speech of normal tone and rate. The patient does not demonstrate abnormal mannerism such as tremors and tics. The patient denies illusions, delusions, and hallucinations. His mood is anxious. The patient denies suicidal thoughts, plans, or attempts.

Differential Diagnoses:

Social anxiety disorder: Social anxiety disorder is the client’s primary diagnosis. Social anxiety disorder is a mental health disorder that is characterized by significant anxiety or fear about social situations that a patient is exposed to potential scrutiny by others. Patients may have fear or anxiety in talking about or being observed in social situations involving others. The social situation or encounter often results in fear or anxiety, which are beyond the actual threat associated with the situation and to its sociocultural context. The fear and anxiety results in avoidance of situations that predispose the patient to the problem. There is also the impairment in social or occupational functioning and distress. The symptoms persist for at least six months and cannot be attributed to causes such as medications use, mental health problems, or substance use and abuse (Koyuncu et al., 2019; Rose & Tadi, 2023). The patient in the case study has significant fear and anxiety towards revealing his sexuality. He fears rejection and the unknown reaction by his colleagues. The fear affects his interaction with others in his work as a soldier. Therefore, social anxiety disorder qualifies as the primary diagnosis.

NRNP 6635 Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD

Generalized anxiety disorder: Generalized anxiety disorder is the client’s secondary diagnosis. Generalized anxiety disorder is a mental disorder that is characterized by excessive fear or worrying about things or events. The fear and worry are beyond the patient’s control. Patients may also report accompanying symptoms such as restlessness, fatigue, and difficulty in concentrating among others. The patient in the case study demonstrates excessive fear towards revealing his sexuality. He fears the repercussions associated with his decision to inform others about his sexualty. The fear the patient has cannot be attributed to medication use, a medical condition or substance abuse (DeMartini et al., 2019). However, the client does not have the accompanying symptoms such as restlessness, making generalized anxiety disorder a secondary diagnosis.

Post-traumatic stress disorder: Post-traumatic stress disorder is the other differential diagnosis that may be considered for the patient. Patients with this disorder experience avoidance, fear, and anxiety symptoms (Lewis et al., 2020). However, it is the least likely cause of the client’s problem since the client does not have any related traumatic experiences or exposures.

Obsessive compulsive disorder: The other secondary diagnosis to be considered for the patient is obsessive compulsive disorder. Patients diagnosed with obsessive compulsive disorders often experience obsessive thoughts that result in compulsions and repetitive behaviors (Goodman et al., 2021). However, this is a least likely cause of the patient’s problem because of the lack of obsessions, compulsions, and repetitive behaviors.

Panic disorder: Panic disorder is the last potential diagnosis that should be considered for the patient. Panic disorder is a mental health disorder characterized by experiences of intense panic or fear towards situations. Panic disorder is the least likely cause of the client’s problem because of the lack of sudden, intense fear or panic and associated symptoms such as shortness or breath or palpitations (Breilmann et al., 2019).

Reflections:I agree with the nurse preceptor’s diagnosis. The symptoms the client has are similar to those seen among patients diagnosed with social anxiety disorder. One of the things that I would do differently should I experience a similar situation is initiating a patient with social anxiety disorder on treatments such as group or individual posychotherapy. Psychotherapy would help the patient to develop effective coping strategies against the triggers of the disorder. I am interested in researching more about the effect of sociocultural factors on the decisions of the patients to reveal their sexuality.

References

Breilmann, J., Girlanda, F., Guaiana, G., Barbui, C., Cipriani, A., Castellazzi, M., Bighelli, I., Davies, S. J., Furukawa, T. A., & Koesters, M. (2019). Benzodiazepines versus placebo for panic disorder in adults. Cochrane Database of Systematic Reviews, 3. https://doi.org/10.1002/14651858.CD010677.pub2

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder. Annals of Internal Medicine, 170(7), ITC49–ITC64. https://doi.org/10.7326/AITC201904020

Goodman, W. K., Storch, E. A., & Sheth, S. A. (2021). Harmonizing the Neurobiology and Treatment of Obsessive-Compulsive Disorder. American Journal of Psychiatry, 178(1), 17–29. https://doi.org/10.1176/appi.ajp.2020.20111601

Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: Diagnostic and therapeutic challenges. Drugs in Context, 8, 212573. https://doi.org/10.7573/dic.212573

Lewis, C., Roberts, N. P., Andrew, M., Starling, E., & Bisson, J. I. (2020). Psychological therapies for post-traumatic stress disorder in adults: Systematic review and meta-analysis. European Journal of Psychotraumatology, 11(1), 1729633. https://doi.org/10.1080/20008198.2020.1729633

Rose, G. M., & Tadi, P. (2023). Social Anxiety Disorder. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK555890/

NRNP 6635 Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD