NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation

  Subjective:CC (chief complaint):
 “My fiancé suggested, well demanded that I make an appointment.” We were at the fair with family with no warning fireworks went off, “I took off running. Fast as I could. Tried to find cover.”HPI: BS is 27 years-old Caucasian male presenting to the clinic today for a psychiatric evaluation for symptoms of PTSD. BS has never been diagnosed with a mental health disorder and is currently not taking any medications. He is here because his fiancé demanded he gets evaluated. He joined the Marines straight out of high school, working as an artillery specialist, served eight years, and deployed three times to combat zones. Six months ago, he was discharged from the military using his GI Bill to go to school for accounting. He lives with his fiancé about five hours from his family in another state. They moved when she received a better job. BS reports the unexpected sound of fireworks triggered him, causing him to feel frightened and like he was back in the war. Afterward, he stated that he felt pretty shaky. BS explains other sounds that have caused this reaction are a circular saw and a car backfired. He reports recent smells such as singed hair and the smell of diesel have also triggered flashbacks. BS explains the singed hair was traumatic, and he needed to leave the party because it reminded him of his two buddies burning in a blown-up Humvee. He struggled with tears when trying to discuss these events, stating he couldn’t because the memories were “too strong.” BS says stopping at a traffic light with people around you makes him break out in a sweat, shaking, and unable to catch his breath. He is worried someone will put an IED under the car, and he would be trapped inside likefour of his buddies. BS presents with heavy breathing from the conversation. He unable to handle negative situations like when his fiancé argues with her mother, reports wanting “to crawlinto a hole and hide.” I stay in my room all day afraid to sleep, because of nightmares that