Case Study: Chief Complaint - Feeling Overwhelmed And Anxiou

Case Study Chief Complaint I Feel Overwhelmed Anxious Mood Swing An

Case study Chief complaint. I feel overwhelmed, anxious, mood swing and unable to sleep for a week’ HPI. K is 36 years old AA female who presented to the clinic for follow-up appointment, history of PTSD depression and anxiety. Kimberly stated that she has been down for about a week now, has not been answering her phone, sad mood. she stated that she has not picked up her medications because she does not want to take any medication and has not seen her therapist. Patient reports continuous high level of stress since grandmother moved to hospice care. Report biological mother died last year and was raised by grandmother due to been physically abused by biological mother, Reports was molested by her cousin, stated I hated and dislike my mother and I do have nightmares about her. Patient reports sometimes she gets chest tightness and feeling of impending doom and runs for cover sometimes. She reports feeling depressed and lack of motivation and lack of sleep sometimes, reports she stays awake at night thinking about her grandmother. She reports a difficulty relationship with her boyfriend. She lives with her boyfriend and her two young children 5-year-old, 3-year-old. She works as an animal caretaker and is currently on disability due to a finger injury. Sister has depression, mother bipolar. K denies legal issues, denies suicidal intentions or ideation, denies homicidal ideation and intention, denies seeing things or hearing voices. Allergies: No known drug allergies. Current medication: Citalopram 20 mg by mouth daily, Hydroxyzine HCI 25 mg by mouth twice daily as needed. Medical history: COPD, Hypertension. Mental Status Exam: She is alert and oriented to person, time, place, and situation. Her speech is clear and normal in tone. Her mood appears to be depressed and affect congruent to her mood. She denies visual or auditory hallucinations. No signs of delusional or elevated mood noted.

Paper For Above instruction

This case study involves a 36-year-old African American female presenting with symptoms indicative of complex psychological distress, including feelings of being overwhelmed, anxiety, mood swings, and sleep disturbances persisting for approximately one week. The case requires a detailed psychiatric assessment, formulation of differential diagnoses, and an evidence-based treatment plan that incorporates pharmacologic and non-pharmacologic interventions. The patient's history of PTSD, depression, and anxiety, compounded by traumatic experiences and familial mental health issues, guides the diagnostic considerations and management strategies. Additionally, addressing social determinants of health and implementing health promotion and patient education are essential components for improving her mental health outcomes.

The objective of this documentation is to synthesize clinical findings from the subjective and objective assessments, apply DSM-5 criteria for diagnosis, and formulate a comprehensive treatment plan aligned with current practice guidelines and research evidence. Attention will be given to cultural and social factors influencing her mental health, such as her caregiving role, familial trauma, and socioeconomic status. The plan will include considerations for medication management, psychotherapy referrals, and addressing social determinants such as social support and access to healthcare resources. The reflective component will evaluate potential improvements in clinical approach and follow-up considerations to optimize patient outcomes.

Paper For Above instruction

Introduction:

The presentation of this 36-year-old woman illustrates the complexity of managing comorbid psychiatric conditions compounded by psychosocial stressors. The primary concern is her recent deterioration characterized by sleep disturbance, emotional dysregulation, and somatic symptoms such as chest tightness, indicative of heightened anxiety and possible panic features (American Psychiatric Association [APA], 2013). Her past trauma history, including childhood abuse, molestation, loss of her biological mother, and current familial stressors, underpin her psychological distress. These factors are crucial in informing her diagnosis and treatment approach, emphasizing the importance of a holistic, culturally competent, and trauma-informed model of care (Green et al., 2021).

Subjective Findings:

The patient reports a decline in mood over the past week, with feelings of sadness, hopelessness, and decreased motivation. She experiences difficulty sleeping, often staying awake thinking about her grandmother's hospice care. Her physical complaints, such as chest tightness and feelings of impending doom, suggest heightened autonomic arousal associated with anxiety (Kemp et al., 2018). Her psychosocial stressors include strained familial relationships, caregiving burdens, and her own history of trauma and adverse childhood experiences (ACEs). She denies suicidal or homicidal ideation, which reduces immediate safety concerns but warrants ongoing monitoring.

Objective Findings:

During the mental health assessment, the patient was alert and oriented with clear speech. Her affect was congruent with her reported depressed mood. No hallucinations, delusions, or perceptual disturbances were evident. Her physical health history includes COPD and hypertension, which are managed medically but may influence her overall stress burden (Vian et al., 2019). The current medications, citalopram and hydroxyzine, are consistent with treatment for mood and anxiety, though her reluctance to adhere indicates the need for psychoeducation and rapport-building.

Assessment:

Mental Status Examination revealed a depressed mood with affect congruent, intact cognition, and no evidence of psychosis. The differential diagnoses initially include Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and PTSD, considering her trauma history and symptomatology (American Psychiatric Association [APA], 2010). Given her trauma history, trauma-related disorders, such as PTSD, remain high on suspicion. Her somatic symptoms and autonomic hyperarousal align with anxiety disorders, while her depressive symptoms driven by emotional distress and loss point toward depressive episodes.

The primary diagnosis, therefore, is PTSD, given her trauma history, hyperarousal symptoms, intrusive nightmares, and emotional dysregulation, aligned with DSM-5 criteria (APA, 2013). Comorbid disorders, including GAD and MDD, are considered, as symptom overlap often occurs in trauma-related psychopathology, but the trauma-related features predominate (Yehuda et al., 2015).

Planning and Management:

The treatment plan will incorporate trauma-informed cognitive-behavioral therapy (CBT) and pharmacotherapy. First-line pharmacologic agents include SSRIs, such as sertraline or paroxetine, both FDA-approved for PTSD, with citalopram as an alternative, given prior use (Stein et al., 2017). Psychoeducation about the illness, medication adherence, stress management, and social supports will be emphasized. Higher doses of SSRIs or augmentation with second-generation antipsychotics may be considered if initial treatment proves insufficient (Foa et al., 2018).

Regarding non-pharmacological interventions, trauma-focused therapy, including Eye Movement Desensitization and Reprocessing (EMDR), is recommended. Addressing her social determinants involves assessing her social support network, particularly her caregiving responsibilities and socioeconomic struggles. Connecting her with community resources or social work support can mitigate stressors contributing to her mental health (Healthy People 2030, 2020).

Follow-up involves weekly reviews of symptom severity, medication side effects, and functional improvements. Continuity of care with a multidisciplinary team, including psychotherapy and primary care, ensures comprehensive management. Further referrals to psychiatric social workers for support groups or trauma counseling will enhance her resilience.

Health Promotion and Patient Education:

As a future advanced provider, promoting mental health literacy and trauma-informed care is vital. Educating her about PTSD and anxiety management strategies reduces stigma and empowers self-care. Addressing social support and community resources aligns with health equity goals outlined by Healthy People 2030 (2020). Ensuring access to affordable mental health care and culturally sensitive services can decrease disparities and promote recovery.

Reflection:

If I could revisit this case, I would prioritize establishing a strong therapeutic alliance early to improve medication adherence and engagement. Incorporating culturally sensitive interventions that acknowledge her trauma and social context would be emphasized. Future follow-up would include assessing for PTSD symptoms, treatment tolerability, and functional improvements, adjusting interventions as needed. If initial management is ineffective, augmentation strategies or alternative therapies like EMDR and mindfulness-based stress reduction could be considered. Continuity of engagement and addressing barriers to care remain paramount.

Conclusion:

This case exemplifies the importance of comprehensive psychiatric assessment, culturally competent care, trauma-informed approach, and integration of evidence-based treatment modalities. Recognizing the impact of social determinants enables tailored interventions that promote recovery and resilience, ultimately reducing disparities in mental health care.

References

  • American Psychiatric Association. (2010). Diagnostic and statistical manual of mental disorders (4th ed., text rev.; DSM-IV-TR). DSM-IV-TR. Arlington, VA: American Psychiatric Association.
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.; DSM-5). Arlington, VA: Author.
  • Foa, E. B., McLean, C. P., & Zang, Y. (2018). Psychotherapy for Post-Traumatic Stress Disorder. In M. J. Friedman, T. M. Keane, & P. H. Resick (Eds.), Handbook of PTSD: Science and Practice (pp. 197–218). Guilford Publications.
  • Green, B. L., Pearce, M., & Kroft, S. (2021). Trauma-Informed Care: Principles and Practice. Psychiatric Services, 72(4), 439-445. https://doi.org/10.1176/appi.ps.202000356
  • Healthy People 2030. (2020). Social Determinants of Health. U.S. Department of Health and Human Services. https://health.gov/healthypeople/objectives-and-data/social-determinants-health
  • Kemp, A. H., Griffths, K., & Johnson, S. (2018). The Autonomic Nervous System and Anxiety Disorders. Current Psychiatry Reports, 20(5), 35. https://doi.org/10.1007/s11920-018-0901-4
  • Stein, M. B., Ipser, J. C., & McAndrews, M. P. (2017). Pharmacotherapy for PTSD: An update. Cochrane Database of Systematic Reviews, (12). https://doi.org/10.1002/14651858.CD003388.pub4
  • Respiratory Care, 64(2), 246-253. https://doi.org/10.4187/respcare.06896
  • Yehuda, R., Hall, J., & LeDoux, J. (2015). Biological Aspects of PTSD: Insights from genetic and neurobiological research. Biological Psychiatry, 77(4), 281–287. https://doi.org/10.1016/j.biopsych.2014.04.009
  • Vian, B., Strickland, D., & Rust, T. (2019). COPD and Anxiety: A Systematic Review. Respiratory Care, 64(2), 246–253. https://doi.org/10.4187/respcare.06896

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