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
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.
Freshman at local college and lives in dorm. Parents married and live in New York.
Spirituality: Methodist
All immunizations up to date per patient (no records in hand) and no recent travel outside of the United States.
Dental exam five months ago, flu shot yearly, COVID-19 vaccine, no additional boosters
Regularly wears seatbelt when driving and as passenger
No weapons in the home
Reports usual health as “fine, no issues.” Denies fever, chills, weight changes.
Denies cough, dyspnea, or wheezing.
Denies recurrent infections.
Confirms hx of asthma, currently treated and controlled.
Denies chest pain, palpitations.
G0T0P0AOL0
LMP x 14 days ago
Menarche age 13, cycle 28 days
Current, vaginal itching and burning after starting antibiotics.
Migraines monthly at time of menses.
Denies coordination problems, numbness, tingling, weakness, tremors. Denies seizures.
Denies depression but reports feeling anxious most days with worsening anxiety before classes begin at 9 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 due to anxiety, and some middle-night awakening, waking not feeling rested.
No loss of interest or pleasure in activities although reports she has started to sometimes go out with friends for fear of having anxiety.
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.
No self-inflicted injuries, no frequent thoughts of death, lack of desire to continue living, or suicidal tendency.
No homicidal thoughts.
No pressured speech, impulsive behavior, feelings of grandeur, inflated self-esteem; not easily distracted.
Denies relationship problems, family problems, poor school/work performance, recent separation, job loss, legal problems. Endorses 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.
| Ht | 5’8” |
|---|---|
| Wt | 124 lbs. |
| T | 98.7 |
| P | 82 |
| R | 18 |
| BP | 126/70 |
| BMI | calculate at every visit |
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.
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.
No deficiency on evaluation of connectedness, organized.
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.
No impaired insight, impaired judgment, poor problem-solving.
***No recent labs on file.