NR 547 Week 4 Clinical VISE Assignment (due between Weeks 3 - 5)

2 Neurological: Dizziness during episodes, numbness or tingling in hands or feet, difficulty concentrating, no history of seizures or headaches. Psychiatric: History of generalized anxiety disorder; they have feelings of dread and excessive worry, denies suicidal ideation, no hallucinations or delusions. Past Medical History (PMH) History of generalized anxiety disorder (GAD), moderate Medications None currently reported Family History Mother, 55 y/o: Diagnosed with depression and takes medication for it. History of hypertension. Father 60 y/o; Generally healthy, no significant medical history reported. Sister, 22 y/o; Diagnosed with anxiety disorder during college, currently managed with therapy and medication. Maternal Grandmother: Deceased at age 70, had a history of severe anxiety and panic attacks. Social History Patient lives alone in a small apartment in the city; she works as a saleswoman in a small, high-pressure advertising firm which pays her on commission. She has no friends and spends almost all her time at work. She keeps in touch with family via phone since they live in different cities. She has not seen them in nearly ten years, citing a lack of time due to work. Mental Status Exam Appears anxious, good eye contact, coherent and goal-directed speech, no signs of psychosis Differential Diagnoses Analysis Panic Disorder: 4 Negative findings: No weight loss, heat intolerance, or other signs/symptoms of hyperthyroidism. No palpable thyroid enlargement or tenderness. Analysis: Physical symptoms such as palpitations and sweating could be due to hyperthyroidism. However, the absence of other hyperthyroidism symptoms like weight loss, heat intolerance, vision changes, muscle weakness, diarrhoea or sleep issues, and a goiter makes the diagnosis less likely possible. Ranking of Diagnoses: 1. Panic Disorder 2. Generalized Anxiety Disorder (GAD) 3. Hyperthyroidism Probing Questions 1. Could there be an underlying medical condition contributing to her symptoms that we have not considered? 2. What are the most effective treatment options for panic disorder in a patient with a history of GAD? 3. What strategies can we implement to prevent relapse and manage long-term anxiety and panic symptoms? Plan Management Confirming the Diagnosis • Conduct a thorough psychiatric evaluation using the DSM-5 criteria. • Perform blood tests to rule out hyperthyroidism (TSH, free T4). • Consider ECG to rule out any cardiac causes of palpitations. Medications 6 SSRIs. Sometimes, SSRIs can initially increase anxiety before improving symptoms (Guaiana et al., 2020). • Advise the patient to return sooner if symptoms worsen or if there are any concerns with the medication. For instance, if she starts experiencing more panic attacks or has an emergence of new symptoms such as suicidal ideation. • Provide the patient emergency plan for panic attacks, including whom to contact and when to seek immediate medical attention. Considerations: • Assess the patient’s insurance coverage and ability to afford prescribed medications. • Discuss the availability of generic options and local mental health resources, including low-cost clinics or community programs that are near her location. Self-Directed Learning Reflecting on my performance, I would like to investigate the following topics to enhance my knowledge and skills: