Question

Current Assessment: GENERAL APPEARANCE: Appears anxious, body tense, tired (dark circles under his eyes) RESP CARDIAC: NEURO: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, Alert & oriented to person, place, time, and situation (x4), flat affect, inability to fall asleep Abdomen softnon-tender, bowel sounds audible per auscultation in all four quadrants Voiding without diffic equal with palpation at radial/pedalpost-tibial landmarks only two hours a night, nightmares, flashbacks while GI GU: SKIN: Skin i SUBSTANCE USE: Last use of alcohol 1 years ago. Denies use of other drugs Mental Status Examination: APPEARANCE MOT R BEHAVIOR Casually dressed: facial scars noted; cooperative with interview Walks with a limp. No abnormal motor activity noted Speech is of normal tone and cadence. Anxious affect. Patient states, "I feel nothing" most of the time, but also states that he lies off the handle" a lot. MOOD/AFFECT: he "starties easily" to environmental noises THOUGHT CONTENT: Denies delusions when assessed, somewhat guarded in responses, but no evidence of paranoia. Admits to intrusive thoughts about his time in combat Expresses excessive guilt that "good men died" and "I wasn't able to help." Also states he sometimes thinks he should have died with "his patrol." States he has periods of time in which he has visions (flashbacks) of being back in Iraq PERCEPTION: INSIGHT/JUDGMENT COGNITION: he IED blast, also reports that sometimes he just sees "lashes" of body parts Recognized symptoms as part of PTSD diagnosis but states There is probably nothing that can be done to hel blast. Possible TBI? Reports current difficulty concentrating at times, Stated that he thinks he should have died instead of the men in his unit. Denies current suicide ideation and has no plan, Denies homicidal ideation. x3. Has some memory problems associated with the exact events during the IED INTERACTIONS: SUICIDALHOMICIDAL: 173 What assessment data are RELEVANT that must be reco PHYSICAL Assessment Data:Clinical Sigilficanee: gnized as clinically significant to the nurse? Clinical Significanee: Mental Status Examination:

Answer 1

Physical assessment

Nothing significant other than the sleep disturbance

Mental status examination

It reveals the person appeared to be anxious with depressive cognitions, like I feel nothing.

In thought he had the intrusive thoughts about the flash backs about Iraq about the IED blasts. With a good insight and orientation.

The medical lab result everything comes with in normal with negative for all the substance in the blood test.

So, this case can be formulated as a person with PTSD having significant sleep disturbance and problems in thought about the event and being presented with an anxious face with no delusion or hallucination but a clear-cut history of depressive cognition with suicidal ideation and don’t having nay active thoughts. In the past use of alcohol and abstinent for about 1.5 years.