PTSD, Major Depressive Disorder, And Schizophrenia: NRNP 6665: PMHNP Care Across The Lifespan I Psychiatric Assessment and Differential Diagnosis: A Case of PTSD, Major Depressive Disorder, and Schizophrenia

PTSD, Major Depressive Disorder, And Schizophrenia: NRNP 6665: PMHNP Care Across The Lifespan I Psychiatric Assessment and Differential Diagnosis: A Case of PTSD, Major Depressive Disorder, and Schizophrenia

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint): “ The government are watching me with the drone without my consent”

HPI: J.A is a 43 year old African American who was recently discharged from the hospital due to agreession, threatening to shoot his neighbor, suicide attempt by cutting his wrist,visual and auditory hallucination.  He mentioned that his neighbor works for the government and they always watch him with drone.  He was at the hospital for 13 days and was on medication the whole time.  He was referred by the doctor to seek psychiatric help after hospital discharge.

According to his older sister,  he has not been the same since he came back from his last military tour 8 months ago, but has not had any fight with the neigbors until the recent time. He sometimes has some road rage, but she never know it was an effect from his military time. During the assessment, he mentioned that he been having some flashbacks and is triggered by smell of a burning flames,bbq, traffic, or loud noice.  He barely get out of  the house due to fear of being monitored.

He rates his depression on the scale of 1-10 ( 10 being the worst), he rated it to 7/10),  anxiety 6/10.  He drinks occasionally and smoke marijuana to help him cope or sleep. He was seeing a psychotherapist for depression and PTSD, but was not on medication before his recent hospital admission.  He has good appetite.  He sleeps about 3 to 4 hours at night due to nightmares, but sometime take benedryl to help him sleep.

Substance Current Use: Alcohol, Marijuana.  Denies any other illicit drug use

Past psychiatric history: PTSD, depression

Medication trials and current medications: Respiradone 2 mg daily, Zoloft 50 mg daily, Celexa 10 mg daily, Lisinopril 10 mg daily, Atorvastatin 40 mg at bedtime.

Psychotherapy or previous psychiatric diagnosis: He has being seeing the psychotherapist for the past 3 months.

Family psychiatric history: No family history of mental health problems, suicide, or unknown death before 30 years old.

Medical History:  HTN, HLD

• Allergies: PCN

Reproductive Hx: He has two daughter from his ex-wife. He is sexually active, but not in any relationship.

Psychosocial: Patient was born and raise in Houston Texas, but moved down to East Texas After his high school.  He has two younger brother and one older sister.  He is currently staying with his sister. Both parent died years ago and he is in good relationship with his siblings.  He was married for 14 year with 2 daughters, but divorced 2 years ago. He has a highschool depplmawith some college classes.

He joined the military while in college.  He has an emotional trauma from when he was in Afghanistan. One of his friend was burn when they were in a convoy with a grenade. He has a legal issue with the law after he tried to kill his neigbhor.  No physical or head trauma.  He used to enjoy going to football game with his brothers, and also like to ride motocycle with his friends.

ROS:

• GENERAL: Negative fever, chills or weknessess.
• HEENT: Patient denied any head trauma, Eyes: No eyes pains, or discharges. Ear:No congestion, or ear ache. Nose: No sinus, or rhinorrhea reported. Throat: No sore throat, or dysphagia.
• SKIN: Denies skin burn or rashes
• CARDIOVASCULAR: No hart murmur, tachycardia or any chest pain
• RESPIRATORY: Denies difficulty breathing or frequent coughing.
• GASTROINTESTINAL: No abdominal discomfort, constipation or N/V
• GENITOURINARY: No painful urination, or blood in the urine. Denies flank pain or unpleasant uring odor.
• NEUROLOGICAL: No headaches or dizziness
• MUSCULOSKELETAL: No muscle weakness or broken bone.
• HEMATOLOGIC: No bleeding or anemia reported.
• LYMPHATICS: No enlarged lyph nodes reported
• ENDOCRINOLOGIC: Denies heat or hot intolerance.
• PSYCHIATRIC: Reports nightmares, hallucination and depression.

Objective:

Diagnostic results: N/A

Assessment:

Mental Status