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Week 2 Analysis of Patient History

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Week 2 Analysis of Patient History

Posttraumatic stress disorder, which is commonly shortened as PTSD, is a psychotic condition that is prompted or triggered by distressing events – either witnessing or experiencing them. Some common symptoms range from severe anxiety, nightmares, flashbacks, and uncontrollable thoughts (Miao et al., 2018). Most PTSD patients might encounter temporary trouble coping and adjusting, although they tend to get better with a quick response and appropriate management. However, if these symptoms persist for months and even years, they might affect activities of daily living – resulting in posttraumatic stress disorder. The common symptoms of PTSD include avoidance, negative mood changes, thinking, and changes in emotional reactions and physical responses (arousal symptoms). Approximately 1-6% of adults have PTSD annually (Sareen, 2020).

This paper specifically summarizes the outcomes of an interview with JM (a close friend), his reception of the diagnosis and management of the condition, and what friends and relatives say about his decision to pursue treatment. JM has had PTSD for the past year. Besides his reaction to treatment, JM’s coping skills and social support will be summarized. Finally, the significance of this information (medical history) will be evaluated, particularly how it will direct or inform the development of the care plan for JM.

Background/History of JM’s PTSD

JM is a 25-year-old who lost both parents in a tragic car crash in 2020. His education ended abruptly because he could no longer afford to pay tuition fees. The thought of not completing college does not even seem to worry JM more than the ordeal he underwent preparing for his parents’ burial. It is one year since the traumatic incident occurred, but JM still experiences discernible behavioral, affective, and cognitive symptoms whenever he finds anything that reminds him of the distressing events.

Specifically, he exhibits combative, fleeing, and dissociative behaviors, as well as severe anxiety and flashbacks. He tearfully narrates that he always remembers her mother whenever he visits the kitchen to cook or fetch something. JM has also experienced psychosocial disruption because he no longer eats, showers, or performs simple chores. He also avoids people and things or experiences that might remind him of his parents. Besides emotional numbing, he has diminished interest in even his favorite activities, skateboarding, and has been living in isolation for the past year. See the appendix for some of his responses; when asked, he was asked specific questions concerning his well-being and feelings.

Acceptance of the Diagnosis by the Patient, Family, and Friends

JM seemed unapproachable at first because he was persistently avoiding the interviewer and other people. He explained later that he was trying to avoid situations, objects, activities, conversations, places, and people that would remind him of the stress and depression he underwent during the mourning period. Avoidance is one of the primary symptoms of patients who have PTSD (Miao et al., 2018). He made it clear that even the questioning itself was giving him flashbacks. The interview had to be canceled and rescheduled. The next time (after two weeks), although he was still uncomfortable with the interview, he only accepted because he felt it was time for him to move on with his life, and the only way of doing this was by seeking help.

Part of the reasons why JM was unwilling to partake in the diagnosis process was not only because of the intrusive, involuntary, and recurrent memories but also because of flashbacks and dissociative reactions. JM also indicated experiencing an increase in heart and blood pressure when such memories and flashbacks are invoked. Although he participated in the second session, it was evident that JM was struggling to cope with negative mood alterations. Occasionally, he exhibited signs of dissociative amnesia, which Lancaster et al. (2016) describe as the incapacity to remember key features of the traumatic event. Also, he was constantly caught up in blame outbursts, shouting words like “God is unfair.”

The most challenging part of interviewing JM was that he exhibited alterations in reactivity and arousal. He was very aggressive and easily irritated, which is characteristic of PTSD patients, according to Miao et al. (2018). Furthermore, he was living a reckless life and harbored suicidal ideations. He was drunk and mentioned that he could not sleep without drinking – a new hobby he explained was helping him forget the traumatic events and also sleep soundly without nightmares.

When quizzed about what family members and friends are saying or doing to help him get medical help, JM responded that they had been the source of his inspiration. He explained that they were the reason he accepted to be interviewed in the first place. His uncles have, in fact, been trying for the past month to take him to a counselor.

Coping Skills, Treatment, and Support

There are positive signs that JM is willing to move on and regain his normal life by overcoming the past. The fact that he accepted the interview the second time proves that he is willing to seek help, including diagnosis and treatment. This desire to follow the self-help route is a crucial step in an ongoing process that might help him recover and address intrusion, avoidance, negative mood alterations, and alterations in reactivity and arousal (Lewis et al., 2017).

Furthermore, JM has indicated that he is keen to learn more about PTSD and trauma, even to the extent of joining a support group. He is also willing to explore all treatment options presented to him as long as he can overcome the hallucinations, irritability, and nightmares. For example, he has expressed the aspiration to practice relaxation techniques, participate in outdoor events, talk to people he trusts, like James (brother), and spend more time with positive-minded people. Furthermore, JM is willing to reduce and, after some time, quit drug use completely. Most importantly, he is prepared and eager to start eating a healthy diet to regain his normal weight and get adequate sleep.

The most important part is that JM is excited about the idea of getting professional help to avoid escalating the situation further, which can expose him to other co-morbidities like heart disease. He has expressed the desire to pursue any form of treatment as long as it will work for him, whether family therapy, medication, cognitive behavioral therapy, or any other.

How the Information Will Direct Care Plan Development for PTSD

Typically, before any care plan is developed, a care provider (counselor, physician, or nurse) must be 100 percent sure about what the healthcare plan will be developed for. This is the underpinning for patient assessment (evaluation of the medical history and symptoms) and, sometimes, laboratory diagnosis; the idea is to confirm that a patient is certainly suffering from a specific disease (Wright, Williams, Wilkinson, 1998). Therefore, the information collected above will inform the exact type of management and treatment that MJ will receive. The plan will be tailored to meet or address these particular symptoms and clinical manifestations.

References

Lancaster, C. L., et al. (2016). Posttraumatic stress disorder: Overview of evidence-based assessment and treatment. Journal of Clinical Medicine, 5(11), 105. doi: 10.3390/jcm5110105

Lewis, C. E., et al. (2017). Internet-based guided self-help for posttraumatic stress disorder (PTSD): Randomized controlled trial. Depression and Anxiety, 34(6), 555-565. doi: 10.1002/da.22645.

Miao, X., et al. (2018). Posttraumatic stress disorder: From diagnosis to prevention. Military Medical Research, 5(32). doi: 10.1186/s40779-018-0179-0

Sareen, J. (2020, Dec 30). Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis. Up-to-date, https://www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-assessment-and-diagnosis

Wright, J., Williams, R., & Wilkinson, J. R. (1998). Development and importance of health need assessment. BMJ, 316(7140), 1310-1313. doi: 10.1136/bmj.316.7140.1310

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Question 

Week 2 Analysis of Patient History

The Impact of Chronic Illness

In a Microsoft Word document of 4-5 pages formatted in APA style, describe the information collected about a person with a chronic illness. Please note that the title and reference pages should not be included in the total page count of your paper.

Identify one person from the illness group you chose in Week 1 to interview. The person should not be a patient at the facility in which you work. You can use friends, family members, or coworkers. Do not use the person’s

Week 2 Analysis of Patient History

name in the paper, only initials.

Administer the questionnaire you created in Week 1 to that person and address the following:

On a separate references page, cite all sources using APA format. Helpful APA guides and resources are available in the South University Online Library. Below are guides that are located in the library and can be accessed and downloaded via the South University Online Citation Resources: APA Style page. The American Psychological Association website also provides detailed guidance on formatting, citations, and references at APA Style.

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