Major Case Analysis

Name: Ms. K.L

Age: 43

Gender: Female

Referral: primary care provider

Chief Complaint: “I have had an experience of extensive worry, fear, and anxiousness to the extent that my daily activities are affected”

HPI: The patient is a 43-year-old female who has come to the health setting with the complaint of having had an increase in the issues of fear and worry. The patient has pointed out that the condition started six months ago but has progressively worsened with time. She has posited that she initially went to see a primary care provider who referred her to see a mental health provider.

Medical Hx: The patient has denied having had any issues of hospitalizations or any past issues of concern. She has denied having any health complications in the past.

Psychiatric Hx: The patient has pointed out that she has not been diagnosed with issues of mental health concern in the past.

Surgical Hx: The patient has denied having had any surgical procedures

Medications:   The patient has denied making use of any medications for her condition or any other condition.

Allergies: She has posited that she is allergic to pollen and dust as it leads to her being with issue of sneezing.

Social History: The patient has reported that she is working as an attendant at a gas station but lately she has had a challenge in being able to go to work due to her fear. She has denied having made use of any drugs and that she does not smoke or make use of any illicit drugs.

Family History: The patient reports that her father and mother are in their 70s and that they have had a healthy life but for the last 10 years they have had health issues with her father being diagnosed with depression and her mother with diabetes. She has three siblings who are 45, 39, and 35. The patient has affirmed that each of her siblings is healthy. Her younger brother who is 39 years old is overweight but is managing his weight. She has two children 19 and 17 who are healthy.

Objective:

Vital signs: T=98.6, P=72, BP=.128/92 R=18 , SpO2 =98.4% Height: 5’4’’. Weights: 139 pounds

Physical Exam

SKIN: The patient has denied any issues of itching or any cases of rashes on the skin.

HEENT/ NECK: She has denied having any health issues in her eyes and that she is not with any issues of concern such as itching or tearing in the eyes. She has denied having nasal congestion or a running nose and she does not have a sore throat.

CARDIOVASCULAR: The patient has denied having had any issues of chest pain or discomfort.

RESPIRATORY: The patient has denied having any difficulties breathing

ABDOMEN/GI: The patient has denied having any abdominal pain and that she has not had a change in the bowel movement and the frequency of bowel movement.

MUSCULOSKELETAL: The patient has denied having any muscle or joint pain

GENITALIA: The patient has denied having any burning sensation during urination and has not had an experience of any pain in the lower abdomen.

RECTAL: The patient has denied having any itching or any lump in her rectal areas.

NEURO: The patient denied having any issues of dizziness and headaches.

ALLERGIC/IMMUNOLOGIC: The patient has reported that she is allergic to pollen and dust as it leads to sneezing profusely.

Diagnostic Tests:

The patient has been identified to be having a mental health condition. There could be a need for the patient to be examined and the diagnosis is supposed to be carried out based on the subjective and objective data that is collected. The preference is to ensure that there is an elimination of any other mental health condition that one may be having or any other condition. Thus, there could be a need for an MRI and a brain scan to ascertain that all the structure of the brain is not affected by any trauma or injury.

MENTAL STATUS EXAM: General: The patient is well groomed and is accommodating in that she can reply to the questions without keeping anything back

Speech: The patient has been found to have clear speech and she does not have cases of high and low changes in pitch

Memory: The patient does not have a challenge of any loss of memory as she remembers all the things she is asked.

Psychomotor: The patient can speak and can organize her sentences.

Mood: The patient has an anxious and fearful mood as she cannot even be able to keep eye contact.

Affect: The patient can identify and manage her speech.

Thought content: She has a logical thinking capacity and she can express her thoughts which are seen to be logical.

Thought Process: The patient can think fast and does not have a challenge expressing her feelings.

Insight: She is determined to work but the fears that she has influenced her work.

Impression:

The patient is supposed to be exposed to Generalized Anxiety Disorder 7-item (GAD-7). This will be important as it will ensure that there is an examination of the extent that the mental health has affected the patient. The intention of to get to understand the severity of the condition of the patient.

Final diagnosis:

Generalized Anxiety Disorder: This is the primary diagnosis of the patient as the symptoms that are presented by the patient are aligned with the DSM-5 diagnostic criteria for this condition. The condition as per Yapici Eser et al. (2018) is characterized by issues of severe issues of fear and worry to the extent that it interferes with one day to day activities. The condition as well may result in the patient experiencing challenges such as anxiety and inability to concentrate. The patient, in this case, has affirmed that she has issues of fear and worry that even affect her daily job.

Paranoid personality disorder: Lewis and Ridenour (2020) allude that this is a condition that is featured by the increasing cases of a patient having doubts about themselves and others. Thus, one has a variation in the way that they view others. The patient with this condition as per Bouthier and Mahé (2018) may experience challenges being able to work with others and the patient may become hostile fast and have a challenge accepting criticism. The patient has pointed out that she has had a challenge being able to handle their fears and worry.

Bipolar disorder: This is a mental health disorder that is associated with issues of change in moods of a person in that one may experience issues of high moods or low moods depending on the environment (Gordovez & McMahon 2020). There is a lack of understanding of the actual factors that have caused mood swings including the genes of a person. The patient has not reported any cases of bipolar disorder in her family and hence this is excluded.

Plan

·       The patient should be prescribed Selective serotonin reuptake inhibitors (SSRIs), to help in the suppression of the symptoms that are suffered.

·       Prescribed with Zoloft 20mg twice a day

·       Should be exposed to cognitive behavior therapy to help in the elimination of the negative thoughts that the patient has

·       The patient should have a referral to a psychiatrist if the need arises

·       The following is supposed to be made after 4 weeks.

References

Bouthier, M., & Mahé, V. (2018). Paranoid personality disorder and criminal offense. L’encephale45(2), 162-168.

Gordovez, F. J. A., & McMahon, F. J. (2020). The genetics of bipolar disorder. Molecular psychiatry25(3), 544-559.

Lewis, K. C., & Ridenour, J. M. (2020). Paranoid Personality Disorder. Encyclopedia of personality and individual differences, 3413-3421.

Yapici Eser, H., Kacar, A. S., Kilciksiz, C. M., Yalcinay-Inan, M., & Ongur, D. (2018). Prevalence and associated features of anxiety disorder comorbidity in bipolar disorder: a meta-analysis and meta-regression study. Frontiers in psychiatry9, 229.

 

 

 

 

 

 

 

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