Two pages or less
3 Sections:
I. Summary of symptoms using examples from the case study
II. Differential Diagnoses – again justifying them from the case study
III. Pharmacologic treatment plan (or lack of if you do not feel the symptoms merit one)
Sam is a 43 year old caucasian female, who presents in the office today with anxiety. She reports that she has been married for 20 years and that she has always worried but it has increased since she found out that her husband wants a divorce. He has been seeing his office assistant on the side for the sat 6 month. She found out about the affair 4 weeks ago and when she confronted her husband about a flower purchase on the credit card. He came clean at that time and reports that he has been unhappy for the last 5 years, ever since their son was diagnosed with Autism Spectrum Disorder. The son is now 8. The patient reports that he has progressed well and is high functioning. She had to fight with her husband to continue speech, ABA, and psychotherapy with her son after insurance denied further coverage, saying that he has reached his lifetime maximum.
The patient has never been treated for anxiety and reports that all her life she has struggled with sleep due to her worries, her mind races at night, she cannot turn her thoughts off, often she feels a sense of doom, wondering when the next bad thing will happen. She averages 4-6 hours of broken sleep per night. She never feels rested and is tired and irritable most days.
She saw her PCP 2 weeks ago, had a thyroid panel, B12, folate, CBC, and Vitamin D level done. Her labs were all within normal limits.
She works as a nurse manager and often finds herself struggling to complete tasks and feels that she is ineffective in all aspect of her life. She sought services with her PCP because in the last 4 weeks, her sleep has decreased, and she feels panicked often. She reports nausea, racing heart, sweating, when thinking about the changes that a divorce will cause for herself and her family. Right now the family gets insurance from her husband and that will end. They have 3 other children, 9, 11, and 16. The 16 yo just got a driver’s license and wanted a car. The savings for the car will have to now be used on legal fees, her husband wasn’t to leave her with the house and car payments – but doesn’t want to pay child support, if he lets her keep the house equity.
The patient has a history of an prolonged QT interval, and arrythmias. She has a strong family history of substance abuse and addictions. Her father was an alcoholic and her mother was hospitalized for a suicide attempt.
Upon assessment, you notice that the patient has not washed her hair in several days, her scrubs are wrinkled. She struggles to answer questions quickly, she is always scanning the room, and she has commented several times that your room does not have any windows. Her hands were cold and sweaty, and you notice that she wrings them as she speaks.
She keeps looking at her watch and reports several times that she feels nauseated.
