Assignment Overview:The
final treatment plan will include the primary diagnosis, diagnostic testing
recommended by National Guidelines. Medications, interventions, education,
labs, follow up, referrals. After completing the treatment plan include the
following sections in a large area called ANALYSIS:1. Pathophysiology
and Pharmacology: For the primary diagnoses in the case, write a brief summary
of the underlying pathophysiology and tie pharmacological treatment chosen in
the reversal or control of that pathology.2. Additional
analysis of the case: This includes national guidelines that were or should
have been used to make diagnosis or treatment and review how they applied or
how care was unique but based in guidelines.3. Follow-up/Referrals:
This means how the patient was doing when seen a second time if this applies.
This would be their response to your plan of care. OR when Follow up will occur
and what actions will be taken on the follow up visit. Referrals if indicated.4. Quality:
Include anything that should have been considered in hindsight or changes you
would make in seeing similar patients in the future with the same complaint,
history, exam, or diagnosis. Add anything you learned from discussion in the
class that shed new light on this patient.5. Coding
and Billing. Any or all CPT and ICD-10 codes that should have been used (List
them and name them only.)
The final treatment plan will include the primary diagnosis, diagnostic testing
recommended by National Guidelines. Medications, interventions, education, labs,
follow up, referrals. After completing the treatment plan include the following sections in
a large area called ANALYSIS:
1. Pathophysiology and Pharmacology: For the primary diagnoses in the case,
write a brief summary of the underlying pathophysiology and tie
pharmacological treatment chosen in the reversal or control of that pathology.
2. Additional analysis of the case: This includes national guidelines that were or
should have been used to make diagnosis or treatment and review how they
applied or how care was unique but based in guidelines.
3. Follow-up/Referrals: This means how the patient was doing when seen a
second time if this applies. This would be their response to your plan of care.
OR when Follow up will occur and what actions will be taken on the follow up
visit. Referrals if indicated.
4. Quality: Include anything that should have been considered in hindsight or
changes you would make in seeing similar patients in the future with the same
complaint, history, exam, or diagnosis. Add anything you learned from
discussion in the class that shed new light on this patient.
5. Coding and Billing. Any or all CPT and ICD-10 codes that should have been
used (List them and name them only.
TEMPLATE:
Primary DX: General Anxiety Disorder
Diagnostic Testing Recommended by National Guidelines:
Medications:
Interventions:
Education:
Labs:
Follow-up:
Referrals:
ANALYSIS
1. Pathophysiology and Pharmacology: For the primary diagnoses in the case, write
a brief summary of the underlying pathophysiology and tie pharmacological
treatment chosen in the reversal or control of that pathology.
2. Additional analysis of the case: This includes national guidelines that were or
should have been used to make diagnosis or treatment and review how they
applied or how care was unique but based in guidelines.
3. Follow-up/Referrals: This means how the patient was doing when seen a
second time if this applies. This would be their response to your plan of care.
OR when Follow up will occur and what actions will be taken on the follow up
visit. Referrals if indicated.
4. Quality: Include anything that should have been considered in hindsight or
changes you would make in seeing similar patients in the future with the same
complaint, history, exam, or diagnosis. Add anything you learned from
discussion in the class that shed new light on this patient.
5. Coding and Billing. Any or all CPT and ICD-10 codes that should have been
used (List them and name them only.
References
Anxiety & Depression Association of America (ADAA). (2015, July). Clinical practice review
for GAD. https://adaa.org/resources-professionals/practice-guidelines-gad
Locke, A., Kirst, N., & Shultz, C. (n.d). Diagnosis and management of Generalized Anxiety
Disorder and Panic Disorder in adults. American Family Physician, 91(9), 617-624.
https://www.aafp.org/afp/2015/0501/p617.html
PART 1 WHICH I SUBMITTED – FOR REFERENCE ONLY
Week 6 Part 1 Psychiatry Case Study
Chief Complaint: “I feel apprehensive, restless, distracted throughout the day and am
having a hard time sleeping at night.”
HPI: A.R. is a 45-year-old Hispanic female who presents to the family practice clinic with
complaints of apprehension, restlessness, distractibility and insomnia. Client states she has
been feeling this way for approximately 4 months. At first she dealt with it because she
attributed her symptoms to the stress of her new role as a store manager at a large retail
store, however, the symptoms have only increased in severity in the last three to four
weeks. A.R. states that now she has “started feeling a tightness or pressure” in her chest
which is the reason she decided to seek medical attention. A.R. has twin sons whom she is
putting through college. Admits to being stressed about her ability to continue supporting
her children until they finish college in the next two years. Client is also worried that her
inability to concentrate will affect her work performance. A.R. is worried she may have a
heart attack and leave her children.
PMHx: Diagnosed with hypertension in 2020, otherwise healthy.
SxHx/hospitalizations: Hospitalized only for her cesarean section in 2003 when she
delivered her twin boys.
Childhood illness: chicken pox and mumps as a child.
Vaccinations: Vaccinations are up to date.
Social Hx: A.R. has been divorced for 2 years and is not in a romantic relationship. Works
50-60 hours per week as a store manager. Drinks alcohol socially during major holidays
only. Denies use of tobacco products and use of recreational drugs. Drinks about 4 cups of
coffee daily. Only physical activity is all the walking she does while at work. Does not
exercise and eats fast foods at least five times per week. Sleeps 3-4 hours per night due to
her inability to fall asleep.
Family Hx: Mother has hypertension, hyperlipidemia and diabetes type 2. Father has
hypertension. No siblings.
Current Medications: Lisinopril 10mg daily and multivitamin daily.
Allergies: NKA
Vital signs: BP 130/84, Pulse 98, R 18, T 98.9, O2 Sat 97% on room air
Height and weight: 5’3, 161 pounds
Subjective Review of Systems (ROS)
Constitutional: C/O fatigue and trouble sleeping. Denies weakness, fever/chills, changes in
weight, or night sweats.
Skin: Denies all symptoms for this system.
HEENT: Denies all symptoms for this system.
Respiratory: Denies all symptoms for this system.
Neurological: C/O occasional headaches. Denies weakness, numbness or tingling,
involuntary movements or tremors, syncope or seizures.
Cardiac and Peripheral Vascular: C/O occasional palpitations and tightness/pressure in
chest. Denies chest pain, SOB, exercise intolerance, orthopnea, fainting or claudications.
Musculoskeletal: Denies all symptoms for this system.
Gastrointestinal: C/O increased appetite and occasional constipation. Denies other
symptoms for this system.
Genitourinary: Denies all symptoms for this system.
Psych: C/O feeling restless, stressed, and nervous about everything, “especially the
palpitations”. C/O memory decline and trouble concentrating. Denies suicidal and
homicidal ideations.
GYN: Denies all symptoms for this system.
Hematology/Lymphatics: Denies all symptoms for this system.
Endocrine: Denies all symptoms for this system.
Objective Physical Examination
General: A.R. is a pleasant, well-groomed, overweight, female in no acute distress. Client
appears stated age, and is alert, oriented and cooperative.
Skin: Warm, dry to touch, without skin tenting. Color appropriate for ethnicity.
HEENT: Normo-cephalic and symmetrical. Hair is thick and evenly distributed throughout
scalp.
Eyes: Sclera is white and clear, conjunctiva white, PERRLA, intact EOM’s. Eyes appears
symmetrical, no periorbital edema noted.
Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. No discharge of impacted cerumen.
Nose: Nares patent, mucosa is pink and moist, septum is midline. Sinuses non-tender to
palpation.
Throat: Oropharynx pink and moist with no excaudate, tonsils 2+. No missing teeth noted
and in good repair with no cavities. Tongue is smooth, pink, moist and is midline. Neck is
supple
with no cervical lymphadenopathy or tenderness. Thyroid is non-palpable. Trachea is
midline.
Respiratory: Clear lung sounds in all fields, no adventitious sounds noted. Unlabored
respirations
Without use of accessory muscles, no stridor, or wheezing noted. Symmetrical chest
expansion.
CV: S1 and S2 with RRR noted. No JVD, murmurs, gallops, bruits or displaced PMI noted.
Peripheral pulses equal bilaterally with no edema noted in any extremity. Capillary refill
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