Case Study Analysis Anxiety

Case Study Analysis Example

CC: “I’m really stressed and feel like I’m losing it. I’m so tense that I am having trouble sleeping and fell like I’m a time bomb about to explode.”

HPI:  Patient is a 24 year old female that came to the clinic complaining of restlessness, fatigue, poor sleep, nausea, and headaches. The patient informs that she has been on the edge of worries regarding everything including her school performance, paying her tuition fees, her father’s health and her younger brother too who is a freshman undergraduate at the Colorado state university. patient feels overwhelmed and has even turned down an offer for internship  and reports having ‘episodes’ while at home studying where she feels shaky as her heart races and even has difficulty concentrating in her work. Due to all these factors patient had to seek treatment at an urgent care clinic a month ago and was provided with a prescription for quetiapine to help with anxiety. Patient also reports being easily startled when someone taps her on the shoulder. She also says she has taken a friend’s medication for anxiety which she report that it calms her and she also reports seeing a therapist for several sessions months ago, but she stopped. 

PMH: Knee surgery (age 16, ACL tear while playing soccer), Mild traumatic brain injury (TBI) (age 16 from motor vehicle accident, Treated with levetiracetam for 1 year)/ Mild depression (age 21, resolved with counseling)

FH: Father is alive and living with has CAD and had MI 3 months ago at age 52. Mother is alive and living with depression, treated with venlafaxine. Paternal grandfather is alive living with alcoholism and a maternal aunt who died at age 60 of suicide.

SH: JA is a graduate student in biomedical engineering at the University of Colorado. She lives alone in a condominium and works part-time as a research assistant in the College of Medicine. Nonsmoker. ETOH 2-3 drinks daily.

All: NKDA.

Meds: Levetiracetam 500 mg bid x 12 months for seizure prophylaxis 8 years ago

Quetiapine 25 mg po twice daily as needed – received 30 days’ supply from urgent care physician last week. Ibuprofen 400 mg po prn

ROS: Frequent tension headaches relieved by ibuprofen; muscle ache in shoulders; nausea and intermittent loose stools

PE:

• General: Anxious-appearing 24-year-old woman in no acute distress

• Vital signs
  • BP 130/76 mm Hg, P 88, RR 18, T 37.3oC
  • Weight 169 lb.
  • Height 65 in.
  • Denies pain

Mental Status Examination:

A 24-year-old cooperative, casually dressed, well-groomed female. Appears dysphoric and moderately anxious. Speech is normal in rate and volume. Mood is “irritable” and “sometimes down,” affect congruent to mood. No apparent delusions or hallucinations. Denies suicidal or homicidal ideation. She appears to have good attention and concentration.

Labs:

All WNL

Urine pregnancy test (-)

Urine drug screen (+) benzodiazepine

ECG: QTc 442 ms

I. AP note

A. Present the problem

Patient is a 24 year old female that came to the clinic complaining of restlessness, fatigue, poor sleep, nausea, and headaches. The patient complaints of being on the edge of worries regarding everything including her school performance, paying her tuition fees, her father’s health and her younger brother too who is a freshman undergraduate at the Colorado state university. patient feels overwhelmed and has even turned down an offer for internship  and reports having ‘episodes’ while at home studying where she feels shaky as her heart races and even has difficulty concentrating in her work. This indicates the patient is suffering from anxiety. Her blood pressure is at 154/97

B. Risk Factors

• Age.
• Insecurity
• Excessive workload
• Excessive responsibility
• Gender
• Alcoholism

C. Assessment

1. Evaluation:

JA is a 24 year old female that presents to the clinic with complaints of feeling stressed. She reported feeling tensed had having trouble sleeping and she felt like she was losing it. He patient is also showing signs of anxiety and depression where she is worried about everything in her life including her family members. So far the patient has also reported episodes of anxiety and has this has highly impacted on her career and her relationship with the people close to her. She also informs that has been taking drugs for anxiety. Based on the initial evaluation the patient’s vital sings and temperature are very consistent with her age. In regard to diet the patient reported that she has not been skipping meals due to her situation, however, the patient also reported that binge eating was part of her coping mechanisms whenever she was stress. In regard to developmental assessment, the patient is experiencing excess worry regarding her performance at school, her family members, and her career path and basically about everything that touches her life. She also gets panic attacks, she is easily startled and always worried easily. She has been experiencing a lot of episodes of sleeping disorders and poor concentration.

Home medications:

Levetiracetam 500 mg bid x 12 months for seizure prophylaxis 8 years ago

Quetiapine 25 mg po twice daily as needed – received 30 days’ supply from urgent care physician last week

Ibuprofen 400 mg po prn

2. Determine appropriateness of current medications:

Quetiapine 25 mg – The medication is used in treatment of particular mental or mood condition such as bipolar disorder, depression associated with bipolar disorder, schizophrenia, and episodes of mania. The medication is also instrumental in the treatment of anxiety and depression (Reuman & Abramowitz, 2021). Commonly the drug is known as an anti-psychotic drug, which works by helping the patient restore balance of various natural substances in the brain. Given the patient situation, the drug is appropriate and can help her reduce panic and hallucinations and improve her concentration in school, work, or activities of daily living. The drug also helps the patient think more positively and clearly about herself, reduce levels of anxiety and take a more active role in everyday life. This could also improve her sleep, mood, appetite, and energy levels. The drug will also help her manage severe mood swings and reduce the number of times the mood swings will occur.

1. Indications: Management of various types of anxiety and depression
2. Interactions:  There are several drugs which have been reported to interact with quetiapine and this includes goserelin and leuprolide. The drug also has serious interaction with about 384 different drugs (Redmond, 2019). There is also reported mild interaction with chasteberry, brimonidine, ethanol, and eucalyptus which the patient should be aware of. 

3. The medication is not approved for patients with psychosis or dementia or elderly patients with have dementia-related psychosis or are being treated with anti-psychosis drugs as this puts them at the risk of death based on the short term controlled trials. Usually deaths will occur in the cardiovascular or when the patient has various types of infections like pneumonia. In the case of JA taking the drugs is also likely to increase the risk of suicidal thinking given that she is taking them for anxiety disorder or other psychiatric disorders. It is important to ensure that prescriptions are written for the smallest therapeutically effective quantity and the mental health nurse will be required to monitor and report   any incidences of suicidal ideation to the psychiatrists, this will include other associated behavior such as self-harm. Since the medication contains quetiapine, it is advisable not to take Seroquel or Seroquel XR especially if she reports any form of allergic reaction on any of the ingredient in the drug. 

4. Dosing: patient to continue with the initial dosage of 25 mg po twice daily as required (Whitten, 2021). She should come back for assessment where an increased dosage will be recommended. 

(d) Compliance: Patient claims compliance with medication and says she has never missed any dosage. 

5. Outcomes:  JA is still not responding positive to the drugs. She is still demonstrating lack of concentration and restlessness. Patient still reports having difficulties in sleeping, worries a lot and is easily startled whenever she is in a new environment. She appears disturbed and withdrawn. At this point, this indicate the need to refer the patient to a psychiatric where she will be put on schedule therapy sessions. JA will also be encouraged to continue with her medication dosage until the 30 days are complement. She will also be encouraged to begin lifestyle modifications such as those that will ensure she focuses on activities of daily living, reduce stress eating, and ensure that she stops uncontrolled drinking habit. This is because excessive drinking has also been linked with anxiety disorders. 

3. Additional Information Needed:

• Medication compliance.
• Activity and diet history.
• Compare today’s weight to last week’s.
• 24 hour urine to assess drug and substance use.
• Any social issues.

4. Desired Therapeutic Outcomes

(a) Short Term Goals

For Hospitalization:

• Normal blood pressure
• HR between 60-100
• Reduce alcohol intake or quit
• Stop Binge eating
• Exercise
• Attend therapy sessions by the psychiatrist

For Home:

• (Same as above in addition to below).

• Exercise for at least 30 minutes sessions, 3 times a week.
• Hold therapeutic sessions with family members
• Continue with reduced alcohol intake
• Reduce stress
• Obtain daily weights
• Continue with dosage as indicated

(b) Long Term Goals:

• Reduced cases of suicidal ideation
• Improved quality of life.
• Prevent and reduce hospitalization cases due to anxiety, suicidal ideation or self-harm
• Diet
• Increased activity of daily living
• Stop using anti-anxiety drugs
• Quit alcohol intake
• Be discharged from therapeutic sessions
• Reduced cases of panic and anxiety
• Normal sleep
• Establish strong relationship with family members
• Continue with her education and complete 
• Continue with other forms of lifestyle modifications. 

D. Plan (P)

1. Recommendations

(a) Non Pharmacological therapy:

• Increase physical activity for 3–5 times weekly for at least 30 min. sessions each time.
• Limit the intake of caffeine
• Avoid the use of alcohol
• Implement proper sleep hygiene habits like avoiding the use of electronics before going to bed such as using laptops, reading in bed, not watching TV and avoiding long day time naps. 
• The patient should also avoid binge eating and heavy meals  before bedtime
• Create a dark, cool and quiet space to allow for sleep
• Implement daily exercise  with her health and time allows
• Can enroll to meditation and yoga which is helpful  in relieving symptoms of anxiety (Lee & Lee, 2018).
• Join support groups for people living with anxiety (Redmond, 2019).
• Bonding with family to ensure that they understand each other and work together towards a common goal. 
• Cognitive behavioral therapy is also recommended as a non-pharmacological therapy including anxiety management training (Reuman & Abramowitz, 2021). These therapies should also be given before medication for a mild or moderate case.

(b) Pharmacologic Therapy:

Continue with the current medication and ensure that the patient completes the 30 days dosage. The patient is also advised to stop the drugs in the event that she report of any side effects in interaction. Ensure that medications for anxiety are also discussed with the patient. In the event that she declines these medications, ensure that alternatives are given, especially if anxiety episodes are recurrent. 

(1) Diazepam

Initial dose: 2-10 mg PP q6-12htr, OR

Can also be increased to 25 mg BID if indicated. (Hyder et al., 2017)

NEW MED- the drug will not be initiated until recommended by

the psychiatric assessment report. 

NEW MEDICATION

E or AE	Parameter	Method	Goal	Alter Tx When/If
E	Management of Anxiety	Pt will be administered with the drug based on the recommendation from the psychotherapist	To reduce levels of anxiety and improve the functioning of the patient nervous system	The levels of anxiety increases, evidence of suicidal ideation and reports of sleeping disorder.
E	Treatment of Alcohol withdrawal	Pt reports through daily diary logs	Reduce the levels of alcohol intake on a daily basis.	Doses to decrease or relieve patient off medication when there is improved levels of alcohol intake or if the medication leads to subsequent withdrawal from the alcoholic intake.
AE	Nausea	Pt reports monitoring for consistent reports of nausea.	No s/s of nausea	Pt develops dry mouth, unusual thirst, difficulty urinating or frequent cases of continuous urination.
AE	Loss control of body movements	Pt reports should report any case of loss control of body movement during sessions with the psychiatrist as a strategy of assessing any advanced issue related to the drug intake	Patient will be put to task to complete body movement exercise to ensure that the drugs do not impact activities of daily living	If activities of daily living are affected, or there is no coordination n between the patient body then the medication should be discontinued.

 (2) Amobarbital–Betablocker.

Initial dose: 30 to 50 mg to be given 2 to 3 times daily.  (Katiboina & D., 2023)

NEW MED- will not be initiated until the patient assessment by the psychiatrist recommends that she is started on the medication. 

E or AE	Parameter	Method	Goal	Alter Tx When/If
E	Treatment of anxiety	Through patient reports and monitoring from the psychiatric doctor	Reduction of anxiety levels	Monitor patient vital signs when considering the IV use if they are not at the desired level that it should not be administered through injection. This is because the superficial IM or the subcutaneous injection could be painful and may also produce sterile abscesses or sloughs.
E	Treatment of Insomnia	Pt reports and Monitoring	To act as a sedative for treatment of insomnia. However this is short term to help the patient rest.	Stop if the patient experiences confusion, severe headache, slurred speech, leg weakness, or arm weakness, loss of coordination, trouble walking, feeling unsteady, high fever, very stiff muscles, or tremors. Tx should also be reconsidered if there are serious eye symptoms, blurred vision, sudden vision loss, eye pain, or swelling.  Also if the patient experiences serious heath symptoms, fast or irregular or pounding heartbeats, shortness of breath, pounding heartbeats, sudden dizziness, passing out or lightheadedness.
AE	Irregular heartbeat	Monitoring Daily heat rates	No irregular heart beat documented.	Stop with the heart beat is above 100 bpm or slow at below 60 bpm. Check whether there is a fluttering sensation in the chest area or there is skipping of the heartbeat. Also when the electrical impulses of the heat  is too fast or too slow, or there it is irregular which can lead to the heart beating irregularly.
AE	Fatigue	Pt reports indicating uncontrollable fatigue	No reports of fatigue	Pt reports unable to tolerate fatigue, then the doses should be changed or discontinue medication

(3) Zolpidem–Sedative.

Dose: 5mg for women taken only at night.  (RXList, 2024)

The medication should be taken before bedtime with at least 7 to 8 hours remaining before the scheduled time for awakening. Given that the patient is still in school, it is advisable that the schedules are well set to meet her time. 

NEW MEDICATION

E or AE	Parameter	Method	Goal	Alter Tx When/If
E	Treatment of Insomnia	Pt reports and monitoring at the psychiatric department.	To ensure that the anxiety levels are reduced and the patient is able to sleep normally	If the patient reports being pregnant or plans to get pregnant then the medication should be stopped as it is unknown how the medication can affect the fetus.  Also avoid use if patient reports also indicate severe hepatic impairment is this could also contribute to encephalopathy.
AE	Complex sleep behavior	Pt reports Monitoring at the psychiatric visits for complex sleep behaviors.	Ensure that activities of daily living are nit interfered with.	Discontinue if patient reports falls or severe injuries or injuring those close to them during complex sleep behaviors. The injuries are likely to result to fatal outcomes. Other complex sleep behaviors include eating food, preparing food, making phone calls or lack of sexual drive.
AE	CNS depressant effects	Pt reports increased depression symptoms	No reported cases of depression	Monitor for risk of next-day psychomotor impairment such as driving or an increased level of AMBIEN which is taken with less than full night of sleep. As recommended 7-8 hours since she is an adult. Also if the patient takes higher than the recommended dose, or mixes the drug with alcohol  or those that are likely to lead to an increase level of Zolpidem in the blood then the patient should not drive  or engaging in activities that require high mental alertness. This is because the drug will possibly lead to the risk of prolonged reaction time, sleepiness, dizziness, reduced alertness, blurred or double vision and an impaired driving morning after using the drug. It thus important that during monitoring these aspects are checked and drug is discontinued or dosage is reduced.

References

Hyder, N., Musharraf, S., & Shyum Naqvi, S. (2017). DIAZEPAM-like effects of Lallementia Royleana Benth. (Lamiaceae) seeds in anxiety disorder. Journal of the Neurological Sciences, 381, 607-608. https://doi.org/10.1016/j.jns.2017.08.1713

Katiboina, V., & D., P. (2023, June). Amobarbital: Side effects, uses, dosage, interactions, warnings. RxList. https://www.rxlist.com/amobarbital/generic-drug.htm

Lee, K. S., & Lee, S. H. (2018). Treatment resistance in anxiety disorder: Generalized anxiety disorder and social anxiety disorder. Treatment Resistance in Psychiatry, 207-214. https://doi.org/10.1007/978-981-10-4358-1_14

Redmond, D. (2019). Neurochemical basis for anxiety and anxiety disorders. Anxiety and the Anxiety Disorders, 533-556. https://doi.org/10.4324/9780203728215-38

Reuman, L., & Abramowitz, J. S. (2021). CBT for somatic symptom disorder and illness anxiety disorder. Evidence-Based Treatment for Anxiety Disorders and Depression, 136-151. https://doi.org/10.1017/9781108355605.009

RXList. (2024). Ambien (Zolpidem tartrate): Side effects, uses, dosage, interactions, warnings. RxList. https://www.rxlist.com/ambien-drug.htm#warnings

Whitten, C. (2021, December 2). What are anxiolytics? WebMD. https://www.webmd.com/anxiety-panic/what-are-anxiolytics