+1(978)310-4246 credencewriters@gmail.com
  

SUBJECTIVE

CC

: “I am always anxious most parts of the day.”

HPI

: T.M is an 8-year-old African American who is brought to the clinic by his mother for being too anxious and needs psychotherapy. The Guardian asserts that she sought medical advice and was referred to a psychiatric hospital. The patient reports getting anxious for no reason, even when he attempts to control it.

Substance Use History

: T.M accepts to be using caffeine drinks daily. She denies having ever taken alcohol. Denies also having smoked cigarettes or marijuana. He accepts experiencing withdrawal complications from anxiety, insomnia, and headaches.

Current medications

: Alprazolam 150 mg/day, Tylenol 80 mg/day, Trazodone 150 mg/day, Adapin, 150 mg/day PO, and sertraline 25 mg PO qDay.

Allergies

: NKDA and NKA

Past Medical History

: PMHX of the patient shows signs of GERD, panic anxiety syndrome, and chronic headache.

Social History:

T.M is a social boy who cooperates with others in group settings and group games and dislikes playing alone. He also spends a lot of time talking with his peers and develops lasting and enjoyable group activities and games. He denies taking alcohol or smoking cigarettes by affirming that he has never smoked. He reports practicing eating a healthy diet and physical exercises every morning.

Family History

: T.M is the second child in a family of three children. He lives with both parents. His mother lives with type 2 diabetes complications, and the uncle was diagnosed with schizophrenia and later committed suicide at age 35. His grandmother deceases at the age of 78 from an unknown cause, while the maternal grandfather decease at the age of 80 from cardiac arrest. The grandfather was once diagnosed with Alzheimer’s disease and heart failure.

Allergies

: T.M reports no history of asthma, hives, eczema, or rhinitis.

OBJECTIVE

Vital signs:

Temp: 98.2 F, HR 87, RR 18, BP 121/76, O2 Sat. 98% on RA

General

: The patient appears physically healthy. However, he is showing signs of anxiety, fatigue, feels restlessness. Reports to be having headaches, unexplained pains, stomachaches, and muscle aches. The patient also accepts to be having difficulty of controlling feelings of worry, having falling asleep and problems of staying asleep. Patient reports difficulty of concentrating and being irritable.

Diagnostic Result

: Using the Zung Self-Rating anxiety scale, the patient was tested for the rapid heartbeat, shaking, nervousness, anxiety, and frequent urination. The assessment of the responses shows that the patient suffers from anxiety. The patient feels chest pain, rapid and pounding heart palpitations, shortness of breath, and impending doom. Despite maintaining sobriety, H.M shows panic in many situations and avoids social situations because of fear and feeling embarrassed.

Mental Status Examination

: T.M is an 8-year-old African American male. Throughout the examination, T.M was cooperative with the examiner. He has dressed appropriately, is neatly groomed, and is clean. His speech is coherent and clear daily and shows no abnormal motor activity. He denies any current homicidal ideas and suicidal intentions. He denies visual and auditory hallucinations and shows no evidence of delusional thinking. He is alert and oriented, and his remote memory is intact.

ASSESSMENT

Primary Diagnosis

: Generalized Anxiety Disorder

This primary diagnosis aligns with DSM-5 criteria for diagnosis of GAD because the patient exhibits the main factors the DSM-5 guidelines require a mental health professional to look for in a patient. These include excessive and hindering worry and other physical symptoms such as restlessness, fatigue, irritability, difficulty sleeping, and extreme anxiety and nervousness.

Differential Diagnosis

Anxiety disorder, unspecified, F41.9 (ICD-10) (Active)

: This is a disabling condition that is often undertreated and underdiagnosed. Patient with mental illness is always at risk for suicide and increased risk of cardiovascular-related disorders and death (Sapra et al., 2020). Some of the most common symptoms of the condition are increased worry, chronic, pervasive anxiety, and physical and psychological symptoms such as sleep disturbance, muscle tension, restlessness, irritability, and difficulty concentrating. T.M exhibit all these symptoms, and it is the reason why he is likely suffering from Anxiety disorder, unspecified, F41.9 (ICD-10) (Active) (Sapra et al., 2020). The condition is treated through psychotherapy and effective medications such as serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.

Panic disorder [episodic paroxysmal anxiety], F41.0 (ICD-10).

Panic disorder is a mental condition that makes a person feel and have sudden attacks of fear. A person with panic disorder experiences regular panic, stress, and anxiety for no apparent reason (Chukhlovina, 2020). Some common symptoms of panic disorder are unease, avoidance of certain situations, chest pain, shortness of breath, and racing heart. Panic disorder is unlikely to be the right diagnosis because the patient, in this case, does not experience regular sudden attacks of fear. The condition is treated through psychotherapy and effective medications such as serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors (Chukhlovina, 2020).

Major depressive disorder, recurrent, moderate, F33.1 (ICD-10)

. Depression is a mood disorder that causes a person to be experiencing a loss of interest and sadness. It affects how a person feels, behaves, and think, and it is a cause of significant physical and emotional problems (Kennis et al., 2020). As a result, a person finds it hard to have normal day-to-day activities. Symptoms of the mental disorder include losing interest in all normal activities feeling hopelessness, tearfulness, and sadness. Sleep disturbance, tiredness, lack of energy, anxiety, reduced appetite, weight loss, recurrent thoughts of death, suicidal thoughts, and suicide attempts are some of the symptoms that make major depressive disorder unlikely to be the proper diagnosis (Kennis et al., 2020). The condition is treated through psychotherapy and effective medications such as serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.

PLAN

The plan for psychotherapy of the patient is health promotion activities. Through follow-up activities, the patient will be required to exercise in the form of physical activities such as jogging and walking daily to reduce anxiety symptoms. She will also be placed on a proper food and well-balanced diet and ensure that she seeks emotional support and has a night of adequate sleep. Medication and psychotherapy will be used for the treatment of the patient. Medications will be prescribed to relieve symptoms, and follow-up programmes by the mental health professional will be used to assist the patient in recovery (Huang & Zhao, 2020). Antidepressant medicines such as serotonin reuptake and Serotonin-norepinephrine reuptake inhibitors will be used as they are safe and generally cause fewer bothersome side effects. The psychotherapy will take place in the clinical setting as it will help the patient open up and discuss the condition and related issues. Psychotherapy will help the patient adjust to a current difficulty, identify negative beliefs, and explore relationships and experiences that can reduce anxiety (Huang & Zhao, 2020).

Reflection

Suppose I am presented with a similar patient. In that case, I will focus much on psychotherapy than medication because psychotherapy will help the patient adjust to a current difficulty, identify negative beliefs, and explore relationships and experiences that can reduce anxiety. Talk therapy is an intervention I will use as it will help the patient avoid panic and anxious behaviors. Antidepressant medication such as serotonin reuptake and Serotonin-norepinephrine reuptake inhibitors will be used as they are safe and generally cause fewer bothersome side effects.

Discussion Questions

Have you ever known someone affected by diagnosable anxiety? What were the symptoms? What was the diagnosis?

If you have ever known a person with diagnosable anxiety, how was their life and lives of their family impacted?

What can you do to assist a person with anxiety disorder?

  
error: Content is protected !!