PTSD Diagnosis of a Hispanic Male Patient

PTSD Diagnosis of a Hispanic Male Patient

PTSD Diagnosis of a Hispanic Male Patient

Dear writer this is the case study for PTSD diagnosis. Based on this case study you will develop a care plan and write an analysis.

 

Patient Information: Male patient, Age 49, Race Hispanic

 

Chief Complaint: “I can’t sleep, and I don’t feel myself this past couple of days”

HPI: 49 year-old male patient, presents to the office complaining of unable to get a good night sleep, having a lot of night mares and is feeling irritable at times for the past 2 weeks. Patient is an army veteran, a 911 survivor and a retired NYC police officer. Patient reports, that in light of current events, he has been feeling down, has very little interest on doing anything or even going outside these past couple of weeks, and has been unable to sleep because of nightmares. He also reports of feeling irritable and can’t listen to the news anymore. Patient denies any suicidal/homicidal ideations. Patient reports that he has had nightmares and difficulty sleeping before but, has never seen a doctor for this problem. He states “my wife made me come see a doctor this time, because she thinks I am very depressed”.

 

Medications: None

Allergies: PCN

PMH: None

Surgeries: None

Immunization: Up to date.

Social History: Patient is a retired police officer, who retired about 1 year ago, he lives with his wife and two children ages 18 and 16 year old. Patient does not smoke and doesn’t use any illicit drugs. He reports drinking one beer or one glass of wine a day.

Family History: Mother and father are both alive. Mother has a history of asthma and DM type 2. Father has a history of HTN.

 

Review of Systems: PTSD Diagnosis of a Hispanic Male Patient

 

General: Patient denies any fever, chills or weakness. Denies any weight loss or gain.

 

HEENT: Denies any headache, earache or vision changes. Denies sore throat.

 

Skin: Denies itching, dryness or rash.

 

Cardiovascular: Denies chest pain, palpitations, swelling or activity intolerance.

 

Respiratory: Denies cough, wheezing or shortness of breath.

 

Gastrointestinal: Denies any abdominal pain, Denies any nausea/vomiting/diarrhea. Denies any changes in bowel pattern.

 

Genitourinary: Denies any urinary retention, frequency, urgency, burning or incontinence.

 

Musculoskeletal: Denies any weakness or difficulty ambulating.

 

Neurological: Denies numbness, tingling, tremors.

 

Psychological: Patient reports sleep disturbance, nightmares, irritability and loss of interest. Denies any suicidal/homicidal thoughts. Denies feeling anxious.

 

Physical Exam:

V/S: BP 135/69, HR 81, Temp 97.6, RR 18, Spo2= 99% on RA, height 5’7” and weight 187 lbs.

 

Patient is a 49 year old Hispanic male, who appears to be his stated age. Patient is AOx 3, cooperative, calm and in no apparent distress.

 

HEENT: Head is normo-cephalic. Eyes are clear, PERRLA. Ears pink and no drainage noted. Throat is pink, moist with no exudate. Teeth are in good repair without cavities. Mouth is pink and no lesions noted. Neck is supple, without tenderness or lymphadenopathy. Thyroid is small, firm and midline.

 

Lungs: are equal and clear bilaterally. Unlabored respirations.

 

Cardiovascular: Heart S1 and S2 noted. No murmurs or gallops noted. No edema. Pulses are equal and present on all extremities.

 

Abdomen: Round, soft and nontender. Bowel sounds are active and present on all quadrants. No masses noted.

 

Skin: is warm to touch, dry and intact, color is normal, no diaphoresis, no cyanosis present.

 

Musculoskeletal: ROM intact and equal in all extremities.

 

Diagnostic testing: PHQ 9 score is 4.

 

Please after reading the case study follow all the required steps and guidelines below. Please use references that are no more than 5 years old. Please use USA journals, scholarly articles or books for references. Use at least a minimum of 5 references.

The final treatment plan will include the primary diagnosis based on this case study, which is PTSD, diagnostic testing recommended by National Guidelines for PTSD.

1.Medications

2.Interventions

3.Patient Education

4.Labs (If any labs or diagnostic test needs to be done. If not why not)

5.Follow up

6.Referrals.

After completing the treatment plan include the following sections in a large area called ANALYSIS:

1. Pathophysiology and Pharmacology: For the primary diagnosis PTSD. Write a brief summary of the underlying pathophysiology and tie pharmacological treatment chosen in the reversal or control of that pathology.
2. Additional analysis of the case: This includes national guidelines that were or should have been used to make diagnosis or treatment and review how they applied or how care was unique but based in guidelines.
3. Follow-up/Referrals: When Follow up will occur and what actions will be taken on the follow up visit. Referrals if indicated.
4. Quality: Include anything that should have been considered in hindsight or changes you would make in seeing similar patients in the future with the same complaint, history, exam, or diagnosis.