CASE STUDY: A CASE OF ANXIETY AND INSOMNIA Identification: The

CASE STUDY: A CASE OF ANXIETY AND INSOMNIA Identification: The patient is a 22-year-old single white male seen in a private outpatient mental health office. Patient was referred by his mother. Chief Complaint: “I feel really anxious and angry and I have trouble breathing.” History of Present Illness: Besides feeling anxious, the patient also reports feeling depressed and angry. He has not been sleeping and does not have an appetite. He reports episodes of shaking, shortness of breath, nausea and sweating which occur suddenly. The symptoms started a month ago after a breakup with his girlfriend. She said she did not want to see him anymore and then she started dating his best friend. He started thinking about her all the time and couldn’t focus on his studies. He is worried he will fail his exams. He has been avoiding his friends because he does not want to be around people. He sought help at the urging of his family. Past Psychiatric History: No prior psychiatric treatment. Medical History: No acute or chronic medical conditions; Average height and weight; Poor appetite. History of Drug or Alcohol Abuse: Denied Family History: The patient was raised by his mother and father with his older brother. His father and older brother have a history of panic attacks. Father was very encouraging about the benefits of medication for his panic attacks. PERSONAL HISTORY Perinatal: Full-term vaginal birth. No complications. Childhood: Normal development and achievements. Adolescence: Did well academically in high school; Played hockey. Adulthood: Currently enrolled as a junior in college; Unemployed. No military or legal history. Trauma/Abuse History: Denies bullying or other trauma. MENTAL STATUS EXAM Appearance: Casual dress. Behavior and psychomotor activity: Good eye contact. Initially tapping foot rapidly. Consciousness: Alert. Orientation: Oriented to person, place, and time. Memory: Intact. Concentration and attention: Attentive during interview. He describes poor concentration with school work. He is worried about failing an exam. Visuospatial ability: Not assessed. Abstract thought: Not assessed. Intellectual functioning: Average or above. Speech and language: Normal rate and volume. Perception: No abnormality. Thought process: He has been obsessing about his ex-girlfriend. Thought content: His thoughts center on his ex-girlfriend and these thoughts were confused and angry. He fears that he will fail his exams because he cannot concentrate enough to study. Suicidality or homicidality: Denied. Mood: Anxious, depressed. Affect: Congruent to mood. Impulse control: Good. Judgement/Insight/Reliability: Good. FORMULATING THE DIAGNOSIS (Please answer all questions) 1. Which diagnosis (or diagnoses) should be considered? 2. Please provide support of diagnostic criteria from DSM-5. 3. Please provide diagnostic code with diagnosis. 4. What is the rationale for the diagnosis? 5. What diagnostic tests or tools should be considered to help identify the correct diagnosis? 6. What differential diagnosis (or diagnoses) should be considered? FORMULATING THE TREATMENT STRATEGY 1. What treatment would you prescribe and what is the rationale? 2. Psychopharmacology? 3. Psychotherapy? If so, which therapy? 4. Psychoeducation indicated? If so, what education and to whom? 5. What standard guidelines would you use to assess and treat this disorder? 6. Referrals? CLINICAL NOTES: Please add clinical impressions, nursing diagnoses, outcomes, goals, interventions for this patient. REFERENCES: Please add citations to support your treatment modalities Thank you. Mount Saint Mary College School of Nursing Mental Health Nursing Practicum Patient Log Rubric Focus Unacceptable (0 points) Marginally Acceptable (5 pts) Satisfactory (7.5 pts) Exceptional 15 pts (except for first category which is 10 pts) Grammar, spelling, syntax, use of medical terminology Grammar, spelling has frequent errors. Medical terminology is misused. Unprofessional presentation. Grammar, spelling, appropriate medical terminology with frequent errors Grammar, spelling, appropriate medical terminology is appropriate with minimal errors Grammar, spelling, and medical terminology is appropriate 10pts Chief complaint, History of present illness, Physical presentation of symptoms. Chief complaint, history of present illness is scant. No note on physical presentation of symptoms. Chief complaint, history of present illness, physical presentation of symptoms is appropriate, however missing information relevant to the chief complaint. Chief complaint, history of present illness, physical presentation of symptoms is appropriate. Some non-vital information relevant to chief complaint is missing. Chief complaint, history of present illness, physical presentation of symptoms is complete and appropriate, written in a logical format. Therapeutic Treatment Therapeutic treatment is missing. Therapeutic treatment modality is listed, but vital information is missing. Therapeutic treatment modality is listed, but information given is vague. Therapeutic treatment modality is described thoroughly. Diagnosis / Assessment Missing. Diagnosis and / or assessment are incomplete. Appropriate medical terminology not used. Diagnosis and / or assessment are complete however key components are missing. Diagnosis and / or assessment is complete with clear explanation. Differential Diagnosis Missing Differential diagnosis given is not appropriate for patient described. Differential Diagnosis is appropriate however no explanation is provided. Differential diagnosis is appropriate with clear explanation Plan Missing Missing two components: future therapy plan, labs to be ordered, new or changed medications with dosage, referrals as appropriate. Missing one component: future therapy plan, labs to be ordered, new or changed medications with dosage, referrals as appropriate. Complete plan of care, including future therapy plan, labs to be ordered, new or changed medications with dosage, referrals as appropriate. Discussion Missing Missing two components: patient progress, projection of treatment, therapeutic self-reflection. Missing one component: patient progress, projection of treatment, therapeutic self-reflection. Thorough, describes patient progress, projection of treatment, therapeutic self-reflection.

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."