Tony, age 32, is experiencing post traumatic stress syndrome from his service as an infantry man. During his mental status examination, he displayed a blunted affect and dysphoric mood, being easily startled and annoyed. He endorsed traumatic experiences but refused to provide details. His thought process was logical but he provided limited responses and had intrusive memories, nightmares, and feelings of detachment from others. While his memory was intact, his concentration was reduced due to intrusive thoughts. He recognized some triggering factors for his condition but was unaware of it until his fiancé urged him to seek help.
Tony, age 32, is experiencing post traumatic stress syndrome from his service as an infantry man. During his mental status examination, he displayed a blunted affect and dysphoric mood, being easily startled and annoyed. He endorsed traumatic experiences but refused to provide details. His thought process was logical but he provided limited responses and had intrusive memories, nightmares, and feelings of detachment from others. While his memory was intact, his concentration was reduced due to intrusive thoughts. He recognized some triggering factors for his condition but was unaware of it until his fiancé urged him to seek help.
Tony, age 32, is experiencing post traumatic stress syndrome from his service as an infantry man. During his mental status examination, he displayed a blunted affect and dysphoric mood, being easily startled and annoyed. He endorsed traumatic experiences but refused to provide details. His thought process was logical but he provided limited responses and had intrusive memories, nightmares, and feelings of detachment from others. While his memory was intact, his concentration was reduced due to intrusive thoughts. He recognized some triggering factors for his condition but was unaware of it until his fiancé urged him to seek help.
Tony, age 32, is experiencing post traumatic stress syndrome from his service as an infantry man. During his mental status examination, he displayed a blunted affect and dysphoric mood, being easily startled and annoyed. He endorsed traumatic experiences but refused to provide details. His thought process was logical but he provided limited responses and had intrusive memories, nightmares, and feelings of detachment from others. While his memory was intact, his concentration was reduced due to intrusive thoughts. He recognized some triggering factors for his condition but was unaware of it until his fiancé urged him to seek help.
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MENTAL STATUS EXAMINATION
Patient’s Name: Tony
Diagnosis: Post Traumatic Stress Syndrome Age: 32
General Appearance and Behavior
Appearance • The patient’s general appearance is normal and appropriate. Puffy eyes and dark under eyes are evident due to significant difficulty in sleeping. Behavior • He endorses experiencing several traumatic events, but is unwilling to provide specific details. • He is trying to avoid talking about the traumatic event and is easily annoyed. • He easily gets startled by noise and motion during the interview.
Affect Based on patient’s attitude during the interview process, it is noticeable that there is a blunted affect on his case as he displayed lack of emotion and energy. He barely mentions the facts of his past experiences as an infantry man and does not go into detail on how he felt.
Mood The patient was noted to be in dysphoric mood and restless all throughout the interview process.
Thought Process The patient had a linear, logical, and coherent thought as he never provided multiple, unnecessary details nor he shifted from the focused questions. However, he provided limited responses. He was able to report his symptoms – difficulty sleeping, nightmares, hypervigilance, lack of interest, feeling of isolation, and intrusive thoughts, as well as he endorsed experiencing traumatic events during his second tour as an infantry man but refuse to disclose specific details. His speech pattern and tone, on the other hand, seemed to be dull and limited. Thought Content The patient is displaying signs of persecutory delusions as evidenced by being easily startled by noise and motion and spending excessive time searching for threats that are never confirmed both on duty and at home. It was noted that he experiences intrusive memories on a daily basis as well as nightmares when falling into a deeper sleep. He also reported that he has significant difficulty in sleeping, that he “sleeps with one eye open”. Furthermore, his thought content revealed feeling of detachment of others as he avoids seeing his friends from his Reserve unit because seeing them reminds him of experiences he does not want to recall and also he spends much of his time alone because he feels annoyed and does not want to burst out at people. There is feeling of isolation but never had suicidal ideations or self-destructive thoughts.
Cognitive Evaluation During the interview process, the patient was correctively aware of time, place and people however his responses to questions were hesitant. Also, he refuses to provide specific details and share precise information but when he does, it is limited. It shows that he has a reduction of concentration due to the intrusive thoughts that he experiences on a daily basis. He can recall experiences from past to recent scenarios and experiences hence it can be concluded that he has intact memory.
Insight The patient's inability to make a definite response stems from his desire to suppress his intrusive and traumatic experiences. The insight of the patient was moderately impaired since he recognized the triggering factors but was unaware of his condition until his fiancé addressed his behavioral changes that have negatively affected their relationship and urged him to seek medical assistance.
Judgement Despite the reluctance of the patient to disclose precise details about his past events, he has displayed his intention in improving his current situation and providing important information to allow healthcare practitioners to understand him better. When it comes to dealing with his feelings, the patient will require further counseling and examination.
