Week 2 Discussion
a. Subjective data: chief complaint, history of present illness, demographic
data, risk factors, previous medical, surgical, and psychiatric history
In the clinic, M.L., a 31-year-old G3P3 Caucasian female, complains of feeling low,
having poor sleep quality, lack of motivation, and general fatigue that has
worsened over the last two months. Her past medical history includes
hypothyroidism, and her surgical history is unremarkable. Her children are ages 5
y/o, 3 y/o, and 3 months old. Her significant other is present and supportive in the
home. Extended family is also close.
b. Objective data: Physical exam findings and mental status exam
Upon initial encounter, the patient appears disheveled and dressed in baggy
clothing. Speech is slowed. Cardiac, respiratory, neurologic, GI, GU, HEENT, and
muscular exams are unremarkable. A psychiatric exam shows M.L. is easily tearful,
but is alert and oriented completely.
c. Recommended diagnostic tests
M.L. has been provided with the PHQ-9 and GAD-7 screening tools. The lab has
collected a CBC, BMP, and a Thyroid Panel.
Alyssa,
Differential Diagnosis:
Post-Traumatic Stress Disorder (PTSD)
Generalized Anxiety Disorder (GAD)
Adjustment Disorder with Anxiety
Top Diagnosis:
PTSD
The diagnosis of PTSD has not always been well understood, and more remains to
be uncovered. As described in your patient scenario, the 40 y/o male presented
with symptoms of hypervigilance, nightmares, and anxiety. These are classic
symptoms of someone suffering from PTSD. Ressler et al., describe hypervigilance
as a, “heightened state of active threat assessment” (2022). This leaves many in a
constant state of anxiety, the fight or flight response is constantly aware. PTSD
occurs typically in approximately 6% of the general population. This statistic
skyrockets to 25-35% when looking at veterans, assault victims, and refugees. As a
recently returned military man, this increases the patient’s risk of developing this
diagnosis. To make an official diagnosis of PTSD, symptoms begin within one
This study source was downloaded by 100000898182462 from CourseHero.com on 05-03-2025 11:47:51 GMT -05:00
https://www.coursehero.com/file/249175080/NR603-Week-2-Discussiondocx/
a. Subjective data: chief complaint, history of present illness, demographic
data, risk factors, previous medical, surgical, and psychiatric history
In the clinic, M.L., a 31-year-old G3P3 Caucasian female, complains of feeling low,
having poor sleep quality, lack of motivation, and general fatigue that has
worsened over the last two months. Her past medical history includes
hypothyroidism, and her surgical history is unremarkable. Her children are ages 5
y/o, 3 y/o, and 3 months old. Her significant other is present and supportive in the
home. Extended family is also close.
b. Objective data: Physical exam findings and mental status exam
Upon initial encounter, the patient appears disheveled and dressed in baggy
clothing. Speech is slowed. Cardiac, respiratory, neurologic, GI, GU, HEENT, and
muscular exams are unremarkable. A psychiatric exam shows M.L. is easily tearful,
but is alert and oriented completely.
c. Recommended diagnostic tests
M.L. has been provided with the PHQ-9 and GAD-7 screening tools. The lab has
collected a CBC, BMP, and a Thyroid Panel.
Alyssa,
Differential Diagnosis:
Post-Traumatic Stress Disorder (PTSD)
Generalized Anxiety Disorder (GAD)
Adjustment Disorder with Anxiety
Top Diagnosis:
PTSD
The diagnosis of PTSD has not always been well understood, and more remains to
be uncovered. As described in your patient scenario, the 40 y/o male presented
with symptoms of hypervigilance, nightmares, and anxiety. These are classic
symptoms of someone suffering from PTSD. Ressler et al., describe hypervigilance
as a, “heightened state of active threat assessment” (2022). This leaves many in a
constant state of anxiety, the fight or flight response is constantly aware. PTSD
occurs typically in approximately 6% of the general population. This statistic
skyrockets to 25-35% when looking at veterans, assault victims, and refugees. As a
recently returned military man, this increases the patient’s risk of developing this
diagnosis. To make an official diagnosis of PTSD, symptoms begin within one
This study source was downloaded by 100000898182462 from CourseHero.com on 05-03-2025 11:47:51 GMT -05:00
https://www.coursehero.com/file/249175080/NR603-Week-2-Discussiondocx/
