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The patient reports that he “cannot handle negative situations.”
History of Present Illness (HPI):
Sergeant Berry Sullivan, a 27-year-old male, has presented for a mental health evaluation following an eight-year service in the military, during which he completed three extended tours in various war zones. He describes a challenging transition to civilian life after his military discharge, which occurred less than a year ago. During his service, Mr. Sullivan was exposed to multiple traumatic events, though he has refrained from providing detailed descriptions of these incidents. He reports that his symptoms, including an inability to cope with negative situations, have progressively worsened since leaving active duty. He denies experiencing flashbacks or nightmares, but notes feelings of irritability and hypervigilance. Additionally, he discloses a troubled childhood marked by an abusive, alcoholic father. Despite these stressors, he has never engaged in substance use due to his father’s alcoholism. Mr. Sullivan denies any prior history of psychiatric disorders, stating that he has never experienced anxiety, PTSD, or major depressive disorder (MDD) symptoms before his recent struggles.
Past Psychiatric History:
General Statement:
The patient was raised in a low-income family with an abusive, alcoholic father. After high school, he joined the military, where he served for eight years, experiencing combat in multiple war zones. He has no documented psychiatric history, but mentions that his paternal grandfather also served in the military and suffered from depression.
Hospitalizations:
No history of psychiatric hospitalizations or mental health treatment.
Medication Trials:
Mr. Sullivan has not undergone any medication trials for mental health conditions.
Psychotherapy or Previous Psychiatric Diagnosis:
The patient denies having previously received any form of psychotherapy or psychiatric diagnosis.
Substance Use History:
Mr. Sullivan has abstained from alcohol and illicit drugs throughout his life due to his father’s severe alcoholism.
Family Psychiatric/Substance Use History:
Paternal History:
The patient’s father is an alcoholic and exhibited abusive behavior during his childhood. His paternal grandfather, also a military veteran, reportedly suffered from depression but never sought professional help.
Psychosocial History:
Mr. Sullivan was raised in a low-income household, and his upbringing was deeply affected by his father’s alcoholism and abuse. His mother remains in good health, but his father suffers from diabetes, liver cirrhosis, and hypertension (HTN). Mr. Sullivan has two siblings, an older sister and a younger brother. He lives with his fiancée and expresses a desire to have children in the future. He is currently unemployed and finding it difficult to adjust to civilian life, contributing to his increased stress and anxiety.
Medical History:
Current Medications:
Mr. Sullivan takes medication for asthma, a condition exacerbated by seasonal allergies, which he attributes to his time in the military.
Allergies:
The patient denies any known allergies.
Reproductive History (Hx):
Mr. Sullivan is not currently a parent, but he and his fiancée hope to have children.
Review of Systems (ROS):
General:
The patient is alert and oriented, with an appropriate appearance and demeanor for the interview. He does not appear to be in any acute distress.
HEENT (Head, Eyes, Ears, Nose, Throat):
No reports of trauma or injury.
Skin:
No rashes or skin irritations.
Cardiovascular:
Denies chest pain or discomfort, no evidence of edema in extremities.
Respiratory:
Reports shortness of breath and occasional difficulty breathing, which he attributes to his asthma and military-related allergies.
Gastrointestinal:
The patient has experienced occasional nausea and vomiting.
Genitourinary:
Denies any genitourinary symptoms, including abnormal urination.
Neurological:
No reported neurological symptoms such as numbness or tingling.
Musculoskeletal:
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