Comprehensive Psychiatric Evaluation: Difficulties Sleeping

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Psychopathology and Diagnostic Reasoning
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Assignment Due Date CC (chief complaint): AA indicates that his fiancée urged him to report to the clinic because of the recent difficulties sleeping and sleeping with one of his eyes open at all times. HPI: AA is a 31-year-old Caucasian male who presents to the clinic for a psychiatric evaluation for sleeping difficulties. He is currently not taking any psychotropic prescriptions. As a result, his fiancée encouraged him to seek psychiatric evaluation and treatment because of the emerging symptoms. The patient describes that he has been grappling with diverse symptoms that range from nightmares related to his infantryman duties in Iraq when in a deep sleep. He also presents withdrawal signs because he loves isolation to avoid snapping at others in society due to his irritability (Carlat, 2017). The patient cannot concentrate on his job, remains startled by slight motions or noises, and becomes obsessed with finding non-existent threats. A psychiatric review of these symptoms demonstrates that their onset started three years ago when he suffered trauma while on military duty in Iraq. The frequency of their occurrence has increased significantly, considering that they are disrupting his daily routines, including work and sleep. Such severity has diminished his quality of life greatly. Past Psychiatric History:

• General Statement: The patient has no history of past psychiatric treatment before reporting to the facility. As a result, this incident marks his first psychiatric encounter.
• Caregivers (if applicable): Fiancée.
• Hospitalizations: The patient’s information indicates that he has no history of hospitalizations, detox, or residential treatments. AA does not display homicidal or suicidal behaviors and has no record of self-harm tendencies presently or in the past.  
• Medication trials: AA has no recorded history of psychotropic medications for AA.
• Psychotherapy or Previous Psychiatric Diagnosis:  AA recognizes suffering from trauma while serving in a local marine reserve in Iraq. However, his case does not mention any treatment initiation.

Substance Current Use and History: Although AA denies abusing any substances, he confesses his ongoing alcohol and nicotine use habits. The patient fails to clarify the amount consumed, frequency, and type of alcoholic drinks or nicotine products. Family Psychiatric/Substance Use History: AA’s family has no history of substance abuse or psychiatric health issues. Psychosocial History: AA is an American-born patient living with his fiancée. The patient does not mention information about his parents, siblings, or children. However, discussions reveal that he is unmarried. His enrollment into the local marine reserve illustrates that he has achieved the minimum educational requirements of a high school diploma and a degree. AA liked spending time alone and worked as an infantryman before his retirement. This exposure left him grappling with war-related trauma. Medical History:

• Current Medications: The patient is currently taking Sertraline 50mg daily. Feduccia et al. (2019) recommend this medication for trauma and PTSD. AA is taking this drug following a confirmed diagnosis of acute stress disorder and PTSD.
• Allergies: AA has no documented allergies against any medications or other substances.

• Reproductive Hx: N/A.

ROS:

• GENERAL: AA appeared exhausted due to his lack of sufficient sleep.
• HEENT: His eyes and vision are clear without signs of impairments. He reports no hearing issues and has no nose or throat-related challenges.
• SKIN: Skin is normal.
• CARDIOVASCULAR: AA denies any presence of heart-related complications, including syncope, discomfort in the chest, pain, or heart attack in the past.
• RESPIRATORY: AA has no known history of wheezing chest or asthma. He is not coughing, producing sputum, or experiencing breathles...