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Assessment and Diagnosis
Mildred’s symptoms suggest that she is suffering from generalized anxiety disorder, as well as panic disorder. A careful, detailed history and evaluation of symptoms should be performed by the provider, while a physical examination can be helpful in determining whether there may be an underlying physical condition. During the interview portion of the exam, Mildred should be asked about her past medical history, current and past medication use, and whether or not she has had any issue with substance abuse. Also, her current social history and life stressors should be explored in further detail, as well as if her family history is positive for any psychiatric illnesses (Baldwin, 2018). Because her symptoms are impacting her quality of life, the interview portion may also be a good opportunity to screen Mildred for depression and suicidal ideation (Locke, Kirtst, & Shultz, 2015).
Differentials, Diagnostic Testing, and Screening Tools
Differentials for this patient could include depression, adjustment disorder, cardiac arrhythmia, hyperthyroidism, and substance withdrawal. An EKG, CBC, CMP, and thyroid panel can typically be done on an outpatient basis to rule out physical causes for Mildred’s symptoms (Locke, Kirtst, & Shultz, 2015). The Generalized Anxiety Disorder Seven-Item Scale (GAD-7) is a useful tool to screen for anxiety in the primary care setting (Baldwin, 2018).
Treatment Options and Follow Up
For patients newly diagnosed with GAD, both pharmacologic treatment and cognitive behavioral therapy (CBT) can be helpful. SSRIs and SNRIs are considered first line medications in treating GAD, as they offer then least amount of side effects while proving to be most effective. Commonly used medications include citalopram, escitalopram, sertraline, paroxetine, fluoxetine, and buspirone. CBT should be provided in therapy sessions, as well as homework assignments to be completed between sessions. Mildred should be rechecked in one month, to see if she is responding to treatment, as it may take up to four weeks for her to notice a difference after starting either an SSRI or SNRI. If needed, the dose of medication can be increased gradually until significant improvement is seen or the maximum dose is reached (Craske & Bystritsky, 2017).
Patient education for Mildred should include a general overview of GAD and panic disorder. Suggestions should also be made as to things she can do on her own to help with her symptoms such as exercise, relaxation techniques, and talking to her friends and family about her feelings. Drug information and side effects should be provided to her as well. She should also know that sometimes it takes time to find the right treatment, medications may have to be adjusted or changed, and that CBT may be ongoing. Mildred should be informed of the importance of close follow up to evaluate how she is doing. Also, she should also be aware that she is to contact the office if she is feeling worse or starts having suicidal ideation (UpToDate, 2018).
Baldwin, D. (2018, April 3). Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. Retrieved from https://www.uptodate.com/contents/generalized-anxiety-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-assessment-and-diagnosis#H448541396
Craske, M. & Bystritsky, A. (2017, December 1). Approach to treating generalized anxiety disorder in adults. Retrieved from https://www.uptodate.com/contents/approach-to-treating-generalized-anxiety-disorder-in-adults#H537101193
Locke, A. B., Kirts, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American Family Physician, 91, 617-624.
UpToDate. (2018). Patient Education: Generalized Anxiety Disorder. Retrieved from https://www.uptodate.com/contents/generalized-anxiety-disorder-the-basics?source=autocomplete&index=2~4&search=generalized%20anxiety%20disorder#H42193731
Mildred is a 45-y.o. Married female with three children. She presents to you with complaints of fatigue and difficulties sleeping. She states she wants to get a good night’s sleep and is requesting a prescription to help her sleep. Mildred tells you she is awake off and on during the night, frequently thinking about her husband’s recent layoff from construction work and the effect this is having on the family. She lies down often during the day and has been so fatigued that she took some time off from work during the last two weeks. She is tearful at times during the visit and looks sad and anxious. On further discussion, she says she feels overwhelmed, helpless, and anxious. She tells you about an episode where she felt her heart beating rapidly, had difficulty catching her breath, felt she was going to have a heart attack and became frightened until her husband was able to help calm her down. She is not eating as much as usual, and when she reads the newspaper, she doesn’t remember what she has read.
According to Baldwin (2018), this patient is experiencing a generalized anxiety disorder (GAD) which is characterized by excessive worry and anxiety that are difficult to control, cause significant distress and impairment, and occur on more days than not. Generalized anxiety disorder is a relatively common disorder, most often with adult onset and chronic course. GAD can lead to significant impairments in role functioning, diminished quality of life, and high healthcare costs. The disorder can be effectively treated with cognitive-behavioral therapy (CBT), medication, or a combination of the two modalities
What would your focused clinical assessment include?
The focused assessment should be along the lines of a psychological assessment. A family history of depression or other mental disorders should be asked since anxiety and depression are common among the elderly population. Asking the patient about any substance abuse or posttraumatic events in their past since according to Baldwin (2018), GAD may also be associated with increased rates of substance abuse, posttraumatic stress disorder, and obsessive-compulsive disorder. Questions about how long the episodes last and has the patient seen anyone for treatment or for evaluation in the past would also be important. Is the patient under much stress, would be information needed during the clinical assessment.
What are your initial differential diagnoses?
The initial differential diagnosis could be panic disorder, anxiety, menopause, depression, thyroid issues, and possible drug abuse.
What major psychological question needs to be addressed?
The major questions to ask would be does the patient experience excessive worry? Does this feeling seem to be getting worse, more frequent, and how much distress does it cause? Another question will be to ask the patient if they find it difficult to control the worry once it starts. Is the patient happy at home or do they have much stress that causes them to worry would be a very important question to ask? Is the patient depresses or having thoughts of harming themselves or others would be another question that would need to be asked?
What testing would you order to rule out any medical problems?
The test needed would be a drug screen, ETOH, CMP, CBC, anemia profile, hepatitis panel, troponin, and a thyroid panel. A head CT scan could also be ordered if the patient is experiencing any headaches or dizziness as some of the symptoms.
What is your plan of care?
The plan of care will be to start the patient on fluoxetine. According to Bystritsky (2018), fluoxetine will help level out the serotonin in the patient. This medication will enhance the serotonin in the body. This medication has fewer side effects and is well absorbed. This medication has a less chance of toxicity and has fewer side effects.
What are the mainstays of treatment?
According to Roy-Byrne (2018), GAD is a relatively common disorder, most often with onset during adulthood and a chronic course. GAD can lead to significant impairments in role functioning, diminished quality of life, and high healthcare costs. The mainstay of treatment is the approach to selecting among treatments for generalized anxiety disorder, including the use of pharmacotherapy and psychotherapy. Selective-serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are efficacious in the treatment of generalized anxiety disorder (GAD). Fluoxetine will be the first drug of choice since it has fewer side effects and has a less chance of toxicity and fewer side effects.
What is your initial follow up plan?
The patient will follow up in two weeks for evaluation and if no change will increase medication. The patient could also receive a psychiatric referral if no change or medications are not working.
What education would you provide to your patient?
The patient should understand how to use the medications and not stop the medication suddenly, because of the possibility of life-threatening conditions could occur. The patient should receive a handout on some relaxation techniques to help with stress or other factors that bother her. Stop smoking and drinking should occur if she has a history of use. The patient should understand to follow up at the clinic or emergency room if any sudden changes should occur such as depression or wanting to hurt themselves.
Baldwin, D. (2018). Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate. Retrieved from https://www.uptodate.com/contents/generalized-anxi…
Bystritsky, A. (2018). Pharmacotherapy for generalized anxiety disorder in adults. UpToDate. Retrieved from https://www.uptodate.com/contents/pharmacotherapy-…
Roy-Byrne, P. P. (2018). Panic disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. UpToDate. Retrieved from https://www.uptodate.com/contents/panic-disorder-i…