Generalized Anxiety Disorder (GAD) – Michael exhibits ongoing anxiety symptoms, including queasiness and nausea, which align with GAD criteria.
Use of the current APA format for PowerPoint (PPT) presentations. Provide a 10-12 PPT .
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Use of the current APA format for PowerPoint (PPT) presentations is expected. Provide a 10-12 PPT slide
Patient has signs and symptoms of at least three psychiatric disorders and one medical condition to create the case: – Generalized Anxiety Disorder (GAD) – Michael exhibits ongoing anxiety symptoms, including queasiness and nausea, which align with GAD criteria.
– Major Depressive Disorder (MDD) – Symptoms of fatigue, lack of motivation, and significant weight loss suggest MDD.
– Panic Disorder – Michael is on medication for panic attacks, indicating a history of panic symptoms.
– Irritable Bowel Syndrome (IBS) – Stress-related gastrointestinal symptoms could be indicative of IBS.
– Adjustment Disorder – The recent stressors of divorce and custody proceedings may be contributing to his symptoms.
Chief complaint: Michael, a 34-year-old male, presents for reevaluation due to ongoing anxiety and depressive symptoms, and for medication management. He stated, 'I lost 20 pounds after my wife and I split, and then I lost 10 pounds being in the hospital for 2 weeks in a row not eating. I just don't have any appetite.
Pt sts he’s taking percocets often with alcohol (vodka). Michael also inquired about the potential benefits of marijuana and microdosing psychedelics for stress and anxiety.
No allergies
Current medications amitriptyline 100mg tablet once a day. Alprozolam 2mg tablet once a day. 5mg PRN
Family HX: non reported, Mother did have depression
No past surgeries
Mental Status Exam
– General Appearance and Behavior: well groomed and cooperative. Michael Ungar appeared engaged and maintained a good rapport throughout the session.
– Motor Abnormalities: No abnormal motor movements
– Affect: Pt. appears to be subdued and expressed a lack of motivation. Affect was congruent with the content discussed, particularly when talking about his ongoing divorce and custody proceedings.
– Mood: "I don't have any appetite. All these meds you put me on take away my appetite."
– Thought Content: Michael expressed concerns about his health, particularly his gastrointestinal symptoms and the impact of his medications. He also voiced feelings of stress related to his divorce and custody proceedings. There is no mention of audiovisual hallucinations, paranoia, or obsessive thoughts.
– Thought Process: linear and goal directed
– Cognition: Grossly intact attention and memory. Michael was alert and engaged throughout the interview.
– Orientation: Alert and oriented
– SI, HI, Violent Ideation: None mentioned.
– Insight and Judgment: Michael demonstrated insight into his condition and the impact of his medications. He expressed a desire to manage his symptoms and improve his situation.
Height: 5 feet (1.52 m) 9 inches (ca. 23 cm) Weight: 195 select BP: 136/70 mmHg HR: 68 bpm T: 98.2° F RR: 14 rpm BMI: 28.8 %tile BMI is currently Overweight.
Michael Ungar was in no acute distress and was cooperative with the exam
– He appeared well-groomed, well-developed, and well-nourished
– BMI was not mentioned
HEENT
– Head normocephalic, atraumatic
– Normal dentition, normal lips, normal gums
– Neck soft, nontender, no increase in JVP visible, no cervical lymph nodes observed
– Breasts, axillary–deferred
Respiratory
– Patient is in no respiratory distress
– No respiratory symptoms reported during the visit
GI
– Abdomen flat on inspection
– Borborygmi x 4
– Soft, non-tender to palpation
– No rebound, guarding, or rigidity observed
GU
– System was deferred
Dermatologic
– Skin normal color, texture, and turgor with no lesions or eruptions.
Musculoskeletal
– Muscle strength was normal limits throughout.
– Extremities state no cyanosis, clubbing, or edema.
– Full range of motion throughout observed.
Neurologic
– CN II-XII intact and non-focal.
– Normal gait and station observed.
– Other findings were deferred.
Psychiatric
– The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal.
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Subjective data: Patient’s Chief Complaint (CC); History of the Present Illness (HPI)/ Demographics; History of the Present Illness (HPI) that includes the presenting problem and the 8 dimensions of the problem (OLDCARTS or PQRST); Review of Systems (ROS). |
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Objective data: Medications; Allergies; Past medical history; Family history; Past surgical history; Psychiatric history, Social history; Labs and screening tools; Vital signs; Physical exam(Focused), and Mental Status Exam. |
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Assessment: Primary Diagnosis and two differential diagnoses including ICD-10 and DSM5 codes. |
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Plan: Pharmacologic and Non-pharmacologic treatment plan; diagnostic testing/screening tools, patient/family teaching, referral, and follow-up. |
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