Loading Anxiety Interactive Case Study


In this assignment, you will review the Anxiety Interactive Case Study patient scenario and analyze the data to determine the health status of the patient.

Select the Patient Subjective Information tab. Within this tab, you will be able to watch a video to gain more insight regarding the patient as well as view important patient details.

For this assignment, you will

  1. Review the Case Study.
  2. Review the Comprehensive Case Study Content Exemplar to understand what is needed within your paper.
  3. Use the Comprehensive Case Study Paper Template to write the assignment in the proper format.
  4. Follow the requirements on the rubric and within the Content Exemplar.
  5. Interactive Comprehensive Case Studies should be 3- to 5-pages in length, excluding the title and reference pages.
  6. Interactive case studies should include a minimum of three evidence-based practice guidelines or articles.
  7. All papers should conform to the most recent APA standards.

Your case study write up should include specific reference to relevant guidelines and other clinical information. The national guidelines should also be considered within treatment plans.

When you have completed viewing the patient information, download the Comprehensive Case Study Paper Template (Word) from the assignment page in Moodle. Use this document to complete the assignment and then submit it to the assignment drop box. Additionally, there is an Exemplar document for review to help guide your case study write up.

Patient Subjective Information


Past Medical History

  • Recent strep throat diagnosis X 1 week, treated, seen at on-campus clinic
  • Vaginal Candidiasis X 4 days, treated




  • Migraine with aura since age 12 (increased prevalence before menses)
  • Dysmenorrhea monthly

Psychiatric History

  • Inpatient and outpatient psychiatric/mental health care: No previous psychiatric inpatient care. Does recall seeing a therapist around the age of 15 for mild anxiety and difficulty managing relationships with peers with lots of fear of rejection, noted she was timid and socially isolated. Saw a female therapist for approximately three months. Reports missing school during this time but therapy helped. No psychotropic medication history. Denies any suicidal ideation or past attempts.
  • Past Psych Diagnosis(es): None
  • Treatments: Outpatient psychotherapy at age 15. Completed approximately 10 therapy sessions.
  • Past Psychotropic Medication Trials: None.
  • Past Psychiatric Medication Trials/Therapy Trials: Reports the therapist assisted her with coping strategies to relax, be less anxious, and manage peer relationships without fear.
  • Outcomes: Reports anxiety subsided and returned to feeling “less stressed” after therapy.

Developmental History

  • Birth History: Fetal alcohol exposure, marijuana exposure in utero.
  • Developmental Delays: Denies any developmental delays.
  • How were they managed? None identified.
  • If any delays what therapies were used, and did they help? N/A
  • Substance Use and Treatment: Denies any use of non-prescription medication, does smoke marijuana two to three times per week as she reports it helps her fall asleep and stay asleep, says she can just chill out to rest. Reports only occasional alcohol use. Denies use of tobacco-non-smoker.
  • Trauma History: Denies any past history of trauma.

Social History

Freshman at local college and lives in dorm. Parents married and live in New Jersey.

  • H— Lives in a college dorm with four roommates. No pets in room. Has good relationship with all roommates and is closest with one friend. Worries sometimes if all her friends actually like her. No recent changes in relationships. Does not think there are any guns in the house but does not have access to all roommate areas.
  • E— Patient does not have a job currently since attending school full-time, works on occasion for catering company at big events (only occasional weekends not regular hours). Patient is a freshman in college. She is starting to feel anxious and nervous prior to attending class, mainly morning classes, but forces herself to go anyway. Spends about an hour a night on homework, states her grades are okay with mostly As, one B, and one C. Is concerned the anxiety is interfering with studies as she has some trouble concentrating when studying.
  • A— Goes to campus gym three times a week but has reported avoiding the gym if anxious. “I’m not going much at all anymore.” Would like to go more often but does not have time with studying and social time. Spends a lot of time after school on social media on phone or on computer. Does not have a car at campus, almost always does wear a seatbelt when in the car with others and when driving self. Hangs out with boyfriend; several girls she lives with are friends while one is her closet friend. Has been with boyfriend for about six months, met before attending college on campus at an admissions event.
  • D— Does not smoke. Has smoked marijuana when anxious some and when she has difficulty falling asleep. Drinks alcohol on social occasion, never fully drunk she states. Has never been in the car driving herself under the influence of drugs or alcohol or with others who are under influence.
  • S— Never had sex in the past but discussing sex with boyfriend after she begins contraception. Wants to move forward with boyfriend as she feels he is “the one” but states she feels very anxious about it.
  • S— Some family hx of depression and anxiety. “My mom has some anxiety and depression I think.” No family history of suicide. Does not feel like she has any relationships that involve anger or discord. Sleeps about four hours each night, reports trouble falling asleep. Awakens frequently during the night.

Spirituality: States “I am spiritual but do not practice anything you should be aware or that would affect my care.”

Family History

  • Mother: 54, hypothyroidism, depression, and anxiety
  • Father: 59, HTN
  • Brother: 18, no complaints or diagnoses
  • Sister: 20, deceased hiking fall accident (20 at death, 2 years ago)
  • Family History of Psychiatric Mental Illness: Unknown
  • Family History of Suicide: Denied

Immunizations and Travel

All immunizations up to date per patient (no records in hand) and no recent travel outside of the United States.

Preventive Health Care

Dental exam six months ago, flu shot yearly, COVID-19 vaccine, non-smoker


Regularly wears seatbelt when driving and as passenger


No weapons in the home

Medications and Allergies


  • Aleve 200 mg, 2 tablets q, 12 hour prn for pain.
  • Midol 200 mg PRN
  • Imitrex 25 mg PO x 1 at start of migraine, may repeat in 2 hours if migraine remains.
  • New: Pen V K 500 mg bid x 10 days #20 no refills.
  • New: Fluconazole 250mg X 1 day no refills.


  • Medication: Sulfa drugs
  • Food: NKA
  • Environmental: NKA
  • Latex: NKA

Review of Systems (ROS)


Reports usual health as “fine, no issues.” Denies fever, chills, weight changes.


Denies cough, dyspnea, or wheezing.

Denies past hx of asthma, recurrent infections.


Denies chest pain, palpitations.



LMP x 7 days ago

Menarche age 13, cycle 30 days

Current, vaginal itching and burning after starting antibiotics.


Migraines monthly at time of menses.

Denies coordination problems, numbness, tingling, weakness, tremors. Denies seizures.

Psychiatric Review of Systems (PROS)


Denies depression but reports feeling anxious most days with worsening anxiety before classes begin at 10 a.m. and also in late afternoon and evening. Anxiety present for the past eight months. Affect is full range. Feels irritable when anxiety worsens, acknowledges feeling tearful and crying for no reasons she can note, reports the presence of some significant stressors: missing family and mother a lot, body image worry, stresses over college courses being hard. States hard time wakening when sleep is disrupted intermittently through night due to worry.


Reports trouble falling asleep almost every night, and some middle-night awakening, waking not feeling rested. Does admit to smoking marijuana two to three nights per week when anxiety keeps her from sleeping.


No loss of interest or pleasure in activities although reports she has started to sometimes go out with friends for fear of having anxiety.

Feelings of Guilt

No feelings of hopelessness, helplessness, hostility, reports she has always had low self-esteem, denies any feelings of guilt or shame or lack of motivation.


No increased energy, reports feeling fatigued most days when sleep is poor.


Some difficulty concentrating when anxiety is increased.


No delusions, hallucinations, feelings of persecution, hearing sounds which seem to be voices, preoccupation with religion.

Self-Harm/Suicide Risk

No self-inflicted injuries, no frequent thoughts of death, lack of desire to continue living, or suicidal tendency.

Homicidal Thoughts

No homicidal thoughts.

Other Mania Symptoms

No pressured speech, impulsive behavior, feelings of grandeur, inflated self-esteem; not easily distracted.

Precipitating Factors

No interpersonal relationship problems, family problems, poor school/work performance, recent separation, job loss, legal problems.

Reports some increased stress with move to college out of town away from family, misses family and mother especially, new boyfriend of a couple months, worries about having sex, worries about grades.


Physical Exam & Vital Signs

Vital Signs:

Ht 5’7”
Wt 122 lbs.
T 99.9
P 92
R 18
BP 121/68

General Appearance

19-year-old Caucasian female in no acute distress, looks same as stated age, normal level of personal hygiene; no inappropriate clothing, no bizarre personal appearance, not overly thin/overweight, no body odor, no unusual behaviors.

Remainder of physical exam deferred during psychiatric mental health assessment.


Mental Status Exam


Alert and oriented X 4, Appearance normal dress and appropriate, behavior speech appropriate. Calm and cooperative.


No tremors or tics; normal gait and stance; no involuntary movements.


Normal rhythm, rate, speed, tone and volume of speech, logical connection of thoughts expressed.


No dysthymic or depressed appears moderately anxious, not dysphoric, euphoric, angry, elevated, expansive, irritable only when more anxious.


Full-ranging, not blunted or constricted, correlates to mood expressed.


No language abnormalities; speech fluent; no dysphonia; no stuttering; language fluent and intact for naming, normal sentence structure.


Patient oriented X4, no disorientation, short-term memory impairment, reduced abstraction ability, ** stated diminished cognitive functioning only when anxiety is at highest, worries grade will decline, worries will need to leave school and go back home.

Thought Process

No deficiency on evaluation of connectedness, organized.

Thought Content

No thought content impairment; denies suicidal ideation, homicidal ideations, denies delusions or hallucinations, denies paranoid ideations, poverty of thought, thought insertions, obsessions, irrational fears, does report fears about others noticing anxiety and avoids friends at times.

Insight and Judgment

No impaired insight, impaired judgment, poor problem-solving.

Lab Values

***No recent labs on file.

Activity is complete.