Case Presentation and Reflection Paper

Case Presentation and Reflection Paper

Case Presentation

My patient was Ms. AN, who was a revisit into the office for the third time. Ms. AN is a 43-year-old female African American patient who first came into the office with mood symptoms and has been on treatment. During this office visit, AN had come for psychiatric evaluation and further treatment.

History of Presenting Illness

AN is a 43-year-old black female who presents for medication management follow-up for generalized anxiety. In the past six months, AN has experienced symptoms of a generalized anxiety disorder (GAD). Four weeks ago, she was diagnosed with generalized anxiety disorder. She reported feeling anxious and worried most days, with symptoms aggravated in the morning. She has been taking medication for GAD, but her symptoms have not significantly improved. She reports difficulty sleeping, fatigue, and muscle tension. Most nights of the week, she finds it difficult to fall asleep or stay asleep and sometimes has to wake up in the middle of the night.

History

At the first presentation, AN reported constant excessive worry about her job and the needs of her children that had occurred for at least four days of the week for about 8 months before this visit. She worked as a car wash accountant for the past six years and had sired 3 children with different men. She has been worried that her job would not meet the socioeconomic needs of her children because some of their fathers didn’t have stable jobs and could not take up custody of the children. The court had denied the fathers of her first two children custodianship of the children due to drug use and lack of stable income. Since she was earning a stable income in her job at the carwash, she was given the custodianship of the children. However, recent developments at her workplace and activities after the pandemic has led to reductions in her earnings.

This patient reported a history of fatigue after work or just before work that happened almost every day. She felt constantly worried about her work and family needs and that she may not be able to provide for her children soon. She also feels that she has lost control of these feelings of worry and they have started to become part of her life. Her sleep quality has deteriorated because she sleeps for about 4 to 5 hours a day and cannot stay asleep for long because she has to wake up midway. She sometimes snaps at her workmates and gets irritable at home. She came to the office because she saw that these symptoms had worsened and had become too much for her social and emotional life, thereby compromising her productivity at work. She denies any phobias or fear of closed spaces. She also reported no history of tremors, trembling, sweating, or preoccupations with death. No changes in appetite or weight were reported in the patient.  She denies any homicidal or suicidal ideations or plans. She denied any fears that come when she is in the presence of peers or other social places. AN was prescribed Zoloft 50mg for her generalized anxiety disorder. However, she was not referred to a therapist for any nonpharmacological treatment.

Medication History

AN was prescribed Zoloft 50mg for her generalized anxiety disorder. H reports taking this medication twice daily as prescribed and has never skipped a dose or overdosed. She denies any other medication uses apart from over-the-counter Advil for occasional headaches.

Social and Environmental Factors

This patient is unmarried and has three children, who all depend on her. Her job, in the beginning, would relieve the economic pressure but not anymore following the recent events at work and in her social life. She admits to being overwhelmed by this socioeconomic pressure. She has the responsibility of being a mother and the family breadwinner. They also report the presence of pressure at work.

Comorbidities

The patient has no comorbid conditions. Even though her mother died at 65 of heart disease and diabetic complications, she is not diabetic or hypertensive. She is neither asthmatic nor epileptic. She has no history of other psychiatric illnesses. She has no hypothyroidism or hyperthyroidism. Her current body mass index is 29.5 and her office blood pressure reading was 117/83 mmHg. She tried smoking recreational marijuana once before her diagnosis but stopped due to hallucinatory side effects.

Mental State Examination

AN is a 43-year-old African American female who looks her stated age. She is cooperative with the examiner. She is cognitively alert and oriented to time, place, and person. Her concentration is good. She is neatly dressed and clean. Her attire is appropriate for the occasion. She is a little fidgety and sits near the front edge of the chair. Her speech is clear, coherent, and normal in volume and tone but has occasional short pauses. Her thought process is goal-directed and logical. The flow of her ideas is logical and does not show any evidence of looseness. Her thinking doesn’t show any evidence of delusions or overvalued ideas. Her mood is objectively tense but subjectively euthymic, and her affect is appropriate to her objective mood. She was trying to smile at times in an appropriate manner. She denies any tactile, auditory, or visual hallucinations. She denies any current suicidal or homicidal ideations. His recent and remote memory is intact. Her insight is intact and judgment appropriate.

Differential Diagnoses

This patient’s outstanding symptom is excessive worry following an identified stressor, which is socioeconomic stress and pressure to meet family needs with her dwindling income. The mental state examination supports the presence of anxiety with anxious mood, fidgeting, sitting at the chair edge, and Pauses in her speech. No evidence of depression or psychotic symptoms is deduced from her MSE. The differential diagnoses include:

1. 3 (F42) Obsessive Compulsive Disorder: This patient’s excessive worry could be due to an obsessional disorder. The constant worry was about a forthcoming or anticipated event or outcomes of an action or current state. However, a lack of compulsion for this obsession makes this diagnosis less likely. According to the American Psychiatric Association (2013, p.225), obsessional thoughts in OCD are associated with excessive worry. However, the thoughts leading to anticipation in OCD are intrusive and inappropriate. Therefore, this diagnosis remains a differential and would require re-evaluation to be considered ahead of the rest.
2. 81 (F43. 10) Posttraumatic Stress Disorder: Posttraumatic stress disorder (PTSD) is characterized by the stress response to the memory of a traumatic event or the re-occurrence of a traumatic event. According to the fifth edition of the diagnostic and statistical manual of mental disorders, anxiety is an invariable feature of PTSD. However, this diagnosis can be ruled out based on a lack of evidence on the presence of traumatic events or memory or traumatic events that trigger these anxieties. Therefore, other items for the diagnosis of PTSD, such as intrusive thoughts, negative mood, cognitive alterations, and hypervigilance, would be important in evaluating this differential diagnosis.
3. 24 (F43.22) Adjustment disorder, with anxiety: this differential diagnosis requires evidence of emotional or behavioral response to an identified stressor. In this patient’s case, the stressor for her excessive worries is identifiable, and she can relate well to the outcomes of these stressors. The symptoms have also significantly impacted her social and occupational functioning because she has lost her productivity at work. This patient’s presentation meets the majority of the criteria for diagnosis of an adjustment disorder. However, the duration of her symptoms exceeds three months. She had felt distraught for 8 months now. Per the criteria for adjustment disorder diagnosis by the American Psychiatric Association, she should not be considered first for this diagnosis, and other causes or diagnoses for her anxiety must be ruled out. The stressors, in this case, have not stopped, and thus, the consequences cannot be assessed post-stressors’ termination.
4. 84 (F19.14) Substance-Induced Anxiety Disorder, with mild use disorder. This patient’s anxiety can also be associated with substance use. There is evidence of substance use in her past just before the beginning of the symptoms. Even though she subjectively admitted to quitting this substance (pot), it was impossible to assess the use in terms of quantity and outcomes. Substance use can cause anxiety, with the associated effects persisting even after quitting these substances. Therefore, ruling out or in this diagnosis would require a comprehensive assessment of her substance use history.

Actual Diagnosis

5. 02 (F41.1) Generalized Anxiety Disorder This patient met criteria A to F for the diagnosis of generalized anxiety disorder according to DSM-5 (American Psychiatric Association, 2013). She has excessive anxiety and worry that occurred for days than not and persisted for more than 6 months. She expressed her subjective lack of control over this worry, and this constant worry had negatively impacted her social and occupational functioning. Her excessive worry could explain irritability and sleep disturbances that were evident. The evaluation of her comorbidities history found no significant comorbid conditions to explain her excessive worry. Her reported substance use was not significant enough to explain her extreme anxiety. She expressed no known phobias or fear of closed spaces. Also noteworthy was the lack of psychotic features for her subjective and objective evaluation. Therefore, the diagnosis of GAD was justified by DSM-5

Interventions Used

My treatment of this patient at first contact was based on the severity of the diagnosis based on the symptoms. Zoloft 50 mg OD dosing was an evidenced-based strategy at first to be used to establish a baseline for stepwise treatment. Sertraline is a selective serotonin reuptake inhibitor used in the management of various mood conditions. This medication works by blocking the reuptake of serotonin from the synaptic space leading to the accumulation and sustained action on the postsynaptic membrane that enhances this neurotransmitter’s pharmacological effects (Huddart et al., 2020). The 2020 updated National Institute of Healthcare Excellence (NICE) guidelines recommend the use of Selective Serotonin Reuptake Inhibitors in the management of generalized anxiety disorder. Zoloft and Escitalopram are two common efficacious medication strategies for the management of GAD (National Institute of Healthcare Excellence, 2019). The goal of treatment dueling this revisit is to reduce the severity of excessive worry and improve sleep quality. The intervention during this revisit was to increase the dose of 100mg per day divided into two doses. The rationale for this intervention is that increasing the dose of sertraline will improve pharmacological and clinical outcomes of treatment by reducing anxiety symptoms (Melaragno, 2021). A pragmatic, double-blind, placebo-controlled randomized trial study by Lewis et al. (2019) found that sertraline improves anxiety symptoms and quality of life in the initial six weeks of treatment better than it does depressive symptoms. However, doses of this medication can be titrated every week or upon evaluation to improve clinical outcomes.

Nonpharmacological interventions included supportive psychotherapy and cognitive behavioral therapy. The chosen supportive psychotherapy modalities chosen were patient education, reassurance, and active listening. In the office, the interventions applied were the provision of comfort and removing any distractions such as noises and excess lighting. These interventions were intended to reduce patient anxiety and increase comfort. Psychoeducation about GAD was offered to the patient to improve their literacy and uptake of the pharmacological and nonpharmacological interventions. For further therapy, the patient was referred to a psychologist for cognitive behavioral therapy sessions. Two 30-minute sessions weekly were prescribed and the next appointment was set for two weeks. This appointment would ensure follow-up and reevaluation of the interventions.

Expected and Actual Outcomes

The desired goal of this intervention is that the patient will achieve more than 6 hours of sleep daily and report a frequency of excessive worry less than three days a week. On the first visit, the intervention did not achieve desired goals. The symptoms worsened instead. The specific goals of this visit’s interventions will ensure that the patient starts to achieve clinical improvement as well as prevention of the recurrence of symptoms. Combining psychotherapy and pharmacotherapy. The patient was still reminded of the risk of suicidal ideations due to the medication prescribed and the absence of suicidality after the first user doesn’t guarantee non-suicidality with subsequent use. Therefore, she was given the emergency contact for the nearest emergency department and advised to alternatively call 911 in cases of suicidal or homicidal feelings.

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Reason for Choosing this Particular Case

At first, this case looked simple and direct; the expectation was that the Zoloft prescription would improve clinical outcomes for this patient. However, I realized that more was needed to improve patient outcomes in this case, as it has in other cases before. I selected this case because it first represented a treatment-resistant case, but I realized that I did not implement a patient-centered approach in this management. I didn’t incorporate patient factors in tailoring the interventions to meet these needs. This patient has psychosocial and economic stressors that could not be solved by medication treatment alone. Therefore, other therapies, such as psychosocial intervention, would be needed.

I also selected this case to demonstrate the need for a multidisciplinary approach to treatment and care for psychiatric and mental health illnesses. At the first visit, the treatment plan was uni-disciplinary and did not include other healthcare professionals in the care of this patient. The multidisciplinary approach would have improved care for this patient by bringing together various specialized care interventions from a specialist such as therapists, psychiatrists, and social workers. Therefore, this particular case was inadequately managed and this second visit offered an opportunity to improve this patient’s management and comprehensively evaluate the patient.

Lastly, generalized anxiety disorder is a fairly common anxiety disorder with significant patient and caregiver safety concerns. This patient’s case was a typical case of GAD that represents the local and worldwide picture of anxiety disorders. A recent cohort study by Slee et al. (2021) in the United Kingdom found that most women have been visiting outpatient clinics and general practitioner offices with generalized anxiety. The recent concern is that the mean age for these patients is becoming younger. Another study by Huang & Zhao (2020) reported that the pandemic has a contributory role in the recent epidemiology of GAD.

Case Reflection

Decision-Making

This particular case presented specific challenges and signs of potential successful outcomes. In reflecting on my clinical practice decision-making, I believe that I handled ANA’s case appropriately and under current best practices. My recommendations were informed by the patient’s symptoms, history, and comorbid conditions. My choice of medication was based on safety profiles, tolerability, and costs, all of which favor the use of sertraline (Kong et al., 2020). As part of the assessment, I also considered social/environmental factors. To facilitate shared decision-making about his care, I provided ANA with education about his condition and treatment options. The responsibility of a licensed mental health professional is to consider these factors when treating my patients. It is also crucial for healthcare providers to establish a collaborative relationship with their patients to provide them with quality care.

Level of Comfort

My level of comfort is high, and I believe I can provide appropriate treatment for GAD. GAD can be debilitating, so it is important to diagnose it correctly and prescribe appropriate treatments. It is my confidence that in the next six months, I will be able to successfully treat my client’s symptoms of GAD and provide ongoing support. It is important, however, to maintain a flexible approach when working with these patients, as some may require more aggressive treatment than others.

What I Might Have Done Differently

If I were to do anything differently, I would have recommended thyroid function studies to rule out hypothyroidism as a cause of this patient’s anxiety. Hyperthyroidism, in some cases, leads to anxiety among patients, as has been documented in various literature items (Shoib et al., 2021). I would also recommend this patient for various therapies, such as physical exercises and yoga, to manage her symptoms. These strategies have been used to treat mood problems as well as other psychological and physical illnesses (James-Palmer et al., 2020). Therefore, I would recommend these additional therapies to improve this patient’s symptoms. Taking a comprehensive approach to manage GAD, as I did for ANA, is also important. It is also important to keep up with current best practices for treating GAD. It is also important to consider symptoms, history, comorbid conditions, and social/environmental factors. To provide the best possible care for the patient, I recommend that they work closely with a multidisciplinary team, including therapists.

Summary

Ms. AN is a 43-year-old African American female who presented with symptoms of Generalized Anxiety Disorder (GAD) that had not significantly improved with medication. A multidisciplinary approach was recommended, including increasing the dose of Zoloft, referral to a therapist for cognitive behavioral therapy and stress management, and education on exercise, diet, and sleep hygiene. The case highlights the importance of considering social/environmental factors and comorbid conditions in the treatment of GAD. My level of comfort is high, and I believe I can provide appropriate treatment for GAD henceforth.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 (R)) (5th ed.). American Psychiatric Association Publishing.

Huang, Y., & Zhao, N. (2020). Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey. Psychiatry Research, 288(112954), 112954. https://doi.org/10.1016/j.psychres.2020.112954

Huddart, R., Hicks, J. K., Ramsey, L. B., Strawn, J. R., Smith, D. M., Bobonis Babilonia, M., Altman, R. B., & Klein, T. E. (2020). PharmGKB summary: sertraline pathway, pharmacokinetics. Pharmacogenetics and Genomics, 30(2), 26–33. https://doi.org/10.1097/FPC.0000000000000392

James-Palmer, A., Anderson, E. Z., Zucker, L., Kofman, Y., & Daneault, J.-F. (2020). Yoga as an intervention for the reduction of symptoms of anxiety and depression in children and adolescents: A systematic review. Frontiers in Pediatrics, 8, 78. https://doi.org/10.3389/fped.2020.00078

Kong, W., Deng, H., Wan, J., Zhou, Y., Zhou, Y., Song, B., & Wang, X. (2020). Comparative remission rates and tolerability of drugs for a generalized anxiety disorder: A systematic review and network meta-analysis of double-blind randomized Controlled Trials. Frontiers in Pharmacology, 11, 580858. https://doi.org/10.3389/fphar.2020.580858

Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., Button, K. S., Churchill, R., Derrick, C., Dowrick, C., Gilbody, S., Fawsitt, C., Hollingworth, W., Jones, V., Kendrick, T., Kessler, D., Kounali, D., Khan, N., Lanham, P., … Lewis, G. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomized trial. The Lancet. Psychiatry, 6(11), 903–914. https://doi.org/10.1016/S2215-0366(19)30366-9

Melaragno, A. J. (2021). Pharmacotherapy for anxiety disorders: From first-line options to treatment resistance. Focus (American Psychiatric Publishing), 19(2), 145–160. https://doi.org/10.1176/appi.focus.20200048

National Institute of Healthcare Excellence. (2019). Generalized anxiety disorder and panic disorder in adults: management (Vol. CG113, p. 17). https://www.nice.org.uk/guidance/cg113

Shoib, S., Ahmad, J., Wani, M. A., Ullah, I., Tarfarosh, S. F. A., Masoodi, S. R., & Ramalho, R. (2021). Depression and anxiety among hyperthyroid female patients and impact of treatment. Middle East Current Psychiatry, 28(1). https://doi.org/10.1186/s43045-021-00107-7

Slee, A., Nazareth, I., Freemantle, N., & Horsfall, L. (2021). Trends in generalized anxiety disorders and symptoms in primary care: UK population-based cohort study. The British Journal of Psychiatry: The Journal of Mental Science, 218(3), 158–164. https://doi.org/10.1192/bjp.2020.159

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A. Case Presentation and reflection Assignment #1 worth 50 points- ADULT PATIENT AGED 21-60
Assignment Description Students will gain experience describing cases they have encountered in their clinical internships; The assignment is to be completed in Two broad ways

1. present the case (with relevant detail),
Case Presentation Assignment 1 – Present and discuss an adult psychiatric patient you have seen DURING CLINICALS, aged 21-60. (choose any psychiatric diagnosis following DSM- 5 criteria) following the steps listed below:

A. Develop the case presentation as you would if giving report or presenting at rounds. Include all the standard components including –
A. HPI,
B. history,
C. medications,
D. social/environmental factors,
E. comorbid conditions,
F. MSE
G. Differential diagnosis;
H. actual diagnosis
I. c Interventions used in this case along with rationales.
J. Expected and actual outcomes.
K. Explain why you chose this particular case.

2. present reflections on the above case presented following the steps listed below:

A. and reflecting on their decision making in clinical practice
B. on your level of comfort,
C. why it was that level,
D. what you might have done differently, and
E. what you would recommend to a colleague about how to handle the situation should they find themselves in a similar situation.
F. SUMMARY
Assignment Evaluation Each of these assignments will be evaluated according to the following rubric:
A.Criteria Points Selects a patient consistent with the prompt 5 points Develops a case B.presentation that includes all of the standard components 30 points
C.Reflection addresses the guidelines in the assignment steps 10 points
D. Recorded and submitted per guidelines 5 points

NOTE : Please use peer review journals, text books for references and cite appropriate Avoid any form of plagiarism.