CCN A Generalized Anxiety in A Caucasian Female Patient Discussion

CCN A Generalized Anxiety in A Caucasian Female Patient Discussion

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Reply:

list three differentials based on the case study provided, Point out the primary diagnosis you are leaning toward, and first line treatment for how you would treat that diagnosis. Use references to support your response.

Case study:

Primary Diagnosis::: Generalized Anxiety

Patient name: L.S.

Age: 31

Gender: Female

Race: Caucasian

Subjective

CC: “Feeling on edge”

HPI: L.S. is in the clinic today with complaints of difficulty sleeping for the past 8 months. She states that she has always been a light sleeper. However, she has only been sleeping an average of 4-5 hours per night. L.S. states “I just can’t shut my mind off.” When asked what she thinks about L.S. said “all kinds of things, but mainly I worry about random day-to-day things, like work, paying bills, housework, family, and school.” She believes that her lack of sleep has caused her to be “irritable and jumpy,” and she has also experienced an increase in tension headaches over the last 2 months. L.S. has attempted treatment with Tylenol PM, but this did not improve her sleep or her headache; says that she decided to come into the clinic because she has been “on edge” and she has noticed that she is easily frustrated at work and at home. “I’m tired of being tired and grumpy.”

PMHx: seasonal allergies, childbirth X 2 (vaginal)

Surgical Hx: Tonsillectomy at age 6

PSHx: L.S. is married to her husband of 6 years, and they have 2 daughters, ages 3 and 5. She is currently employed as a nursing assistant at a community hospital, where she has worked for the last 6 years, and she is enrolled in a part-time nursing program to obtain her BSN- she has 11 months left of the program. L.S. is a non-smoker, drinks 2-4 rum and cokes on the weekends, and occasionally (1-3 times per month) she uses marijuana; 1-2 caffeinated beverages per day, no routine exercise; uses seatbelt.

Family Hx: Mom – depression, hypothyroid, hypertension. Dad – GERD. Sister – Anxiety. Children – Healthy

Current medications: none

Allergies: none

ROS:

Constitutional: difficulty sleeping, fatigue, no fever or chills. No change in appetite

Psychiatric: admits to irritability, jumpiness, difficulty concentrating, racing thoughts ; substance use – Marijuana 1-3 times per month to help her relax

Endocrine: no changes in appetite or intolerance to heat or cold

Diagnostics:

CBC, CMP, TSH

GAD-7: score 16

PHQ-9: score 9

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