Assessing and Diagnosing Patients



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Assessing and Diagnosing Patients with Anxiety Disorders, PTSD, and OCD

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Differential Diagnoses:

Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) refers to a psychiatric condition that occurs and is triggered when a client fails to recover after experiencing or witnessing a terrifying or scary event.   PTSD consists of physical and emotional reactions leading to symptoms which DSM-5identifies as criteria for effective diagnosis of PTSD. Symptoms of PTSD include severe anxiety causing sweating and shaking, flashes of the event, uncontrolled thoughts, nightmares.

 Therefore, following the DSM-5 guideline of PTSD diagnosis, the primary diagnosis is supported by the patient’s personal information. The patient reports running away and looking for cover as he was frightened by the fireworks, which sounded like a combat fire. Also, the patient reports symptoms such as being easily startled, dreaming about events in combat, resulting in having nightmares, having flashbacks about the warzone, and feeling anxious.  The patient also reports he hates traffic as he feels trapped and in fear that someone can roll an IED under the car, causing an explosion, which he witnessed happen to his friends overseas.  In addition, he smells such as diesel or chopper fuel, and the smell of burning meat reminds him of experiences in a warzone.

Furthermore, the patient reports hating loud arguments and does not like going to a restaurant, baseball parks or, shopping and likes staying indoor. Moreover, he says he has never talked about his experience because his stomach muscles get tight, and he starts feeling nauseated. This is evidence that the patient has PTSD.



F41.9 Anxiety disorder, unspecified

Anxiety, according to DSM-5, is defined as the excessive feeling of fear, worry, tension, and nervousness, about a situation or people. Anxiety happens for several days and lasts for about 30 minutes, during which a person cannot control their emotions or situation. Therefore, anxiety disorder is a mental approach to responding to a perceived threat, especially when- a person has dysfunctional coping strategies. Anxiety diagnosis requires a thorough assessment of physical examination and blood test to ensure there is no underlying condition that is causing the symptoms (American Psychiatric Association, 2013). The symptoms of anxiety include fast and high respirations,   feeling stressed, indicating high levels of stress, feeling like having a heart attack, chest tightness, trouble catching a breathe, the hard pounding of the heart with a feeling the heart is going to explode out of the chest.  These feelings are experienced for a few roughly 20 minutes, and they pass but can reoccur for days. It is a differential diagnosis because the patient expressed fear, anxiousness, and shaking, which are some of the symptoms supporting anxiety, but insufficient to make this a primary diagnosis. 

Treatment Plan

Following the subjective and objective analysis, a PTSD diagnosis is accurate, which guides the treatment plan. PTSD is a mental illness with effective treatment using pharmacotherapy, psychological therapy, or a combination of both.  Ensuring the treatment plan is patient-centered and adheres to evidence-based practice results in achieving desired patient outcomes and family satisfaction. 

Pharmacologic treatment plan

The medication a professional prescribes to a patient diagnosed with PTSD are SSRIs, beta-blockers and, mood stabilizers which should help improve the patient’s symptoms when a PTSD attack occurs. Close monitoring for the medication side effect is vital, and necessary activities such as changing or lowering the dosage should be undertaken.  For anxiety disorder, qualified professionals prescribe medication which includes diazepam, clonazepam, alprazolam, or clonazepam to improve patient symptoms during an anxiety attack. With such prescriptions, close monitoring for side -the effect is required. For the differential diagnosis, a psychiatrist should initiate and monitor side effects.


In his case, psychosocial therapy will involve scheduling a face-to-face appointment with the client to provide the client with coping mechanisms and talk therapy to help the brain heal and cope with the patient’s experience in combat. Psychotherapy to treat PTSD includes;

  • Cognitive-behavioral therapy (CBT) for PTSD focuses on teaching a client coping mechanisms to deal with emotions, feelings, and behaviors. Cognitive therapy helps patients identify and correct distorted thinking and emotions, and behavioral therapy uses corrected thinking to enhance behavior change and improve functioning.
  • Prolonged exposure therapy is trauma-focused psychotherapy that enables clients to confront and face frightening safely and avoided memories, situations, and fears to enhance coping mechanisms. Re-experiencing the trauma in a safe environment -is helpful for PTSD patients as exposure allows dealing with event flashbacks, memories and, nightmares to learn coping mechanisms- and make the experience less distressing.

Non-pharmacological treatment 

Non-pharmacological treatment of PTSD involves managing anxiety when exposed to a similar frightening situation by learning mindfulness and relaxation skills such as meditation, regular exercise, and yoga and breathing techniques to cope with stressful and frightening situations, which brings the memory of a traumatic event. Additionally, a balanced diet ensures the body is strong enough to deal with stressful life situations, which can trigger PTSD.


This is the first assessment appointment for the client; therefore, no referral is required, but the psychiatrist should schedule appointments with the patient to provide evidence-based and patient-based treatment to the patient.

Health promotion and education

Health promotion is a personalized patient plan which prevents worsening of the symptoms by creating awareness about PTSD and ensuring every veteran gets the needed help after coming home.  Educating the family members on how to help the veterans, such as accompanying them for mental wellness, ensures they can cope in real life after the war.  Also, encouraging group setting to acquire social support helps deal with a common mental problem which reduces associated symptoms.  Education also involves providing evidence-based information to learn and understand the diagnosis of PTSD and learn about coping strategies through awareness measures and encourage self-diagnose and treatment.


Planned follow-up visits         

This being the first appointment recommended for assessment, a follow-up treatment schedule is vital. For adequate treatment twice a week, follow-up is recommended to provide face-to-face counseling therapy to equip the patient with coping mechanisms and ways of dealing with PTSD-associated memories.


The development of this mental health soap note followed evidence-based provisions to ensure the patient gets the best current and quality care from the interviews process, diagnostic reasoning, to treatment plan.  It also provided me with an excellent opportunity to learn through research and analysis of studies about assessing and diagnosing anxiety, PTSD, OCD, and other conditions under this classification. It is evident that veterans face challenges coping after the way, therefore through this soap note, I have recommended counseling to veterans after the war to cope with everyday life after experiencing and being exposed to grueling warzones. Given another opportunity, I would not do anything differently because this soap note applied evidence-based practice in assessment, diagnosis, and the care plan for the client. Ethical consideration includes confidentiality and consent and ensures the treatment recommended for the patient does not affect functionality.






American Psychiatric Association. (2020). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.

Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93. doi: 10.31887/DCNS.2017.19.2/bbandelow

Knowles, K. A., Sripada, R. K., Defever, M., & Rauch, S. A. (2019). Comorbid mood and anxiety disorders and the severity of post-traumatic stress disorder symptoms in treatment-seeking veterans. Psychological Trauma: Theory, Research, Practice, and Policy11(4), 451.

Stein, D. J., Scott, K. M., de Jonge, P., & Kessler, R. C. (2017). Epidemiology of anxiety disorders: from surveys to nosology and back. Dialogues in clinical neuroscience, 19(2), 127. doi: 10.31887/DCNS.2017.19.2/dstein

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