Demographic data:
G.L. is a 22-year-old Hispanic female
Chief complaint:
G.L. reports feeling increase in heart rate and nervousness when at work, especially when having to speak to a large group of people during meeting.
HPI:
Ms. G.L., a 22 year old Hispanic female, presents to the clinic with reports of feeling very anxious at work and when out in public places with huge crowds such as concert. Patient reports never wanting to stand up in front of the class during high school and college for presentation assignments. Patient reports feeling very nervous and anxious, with her heart racing and faster breathing, when having to do presentations at work. Patient states, as often as she could, she would opt to take online classes to complete her degrees just to avoid the classroom setting. Patient denies taking any medication to help relax and states this is her first time coming out with this issue and wants to see what can be done to improve her fears of audiences and large groups of people.
Current medicaitons:
Patient takes cetirizine 10 mg daily for seasonal allergies in which he takes on an as needed basis
PMHx:
Up to date on all immunizations. No prior hospitalizations. No past medical history, even as a child, reported at this time.
PSHx:
No prior surgeries reported at this time. Patient does report having had a dislocated right shoulder when she was “about 10 years old” and was “knocked out with medication” while they repaired the dislocation of the right shoulder.
Social Hx:
Patient is a recent college graduate with a bachelor’s degree in finance. Recently obtained a position as a financial analyst for a lumber company 4 months ago. Patient lives alone in an apartment, denies any elicit drug use, smoking, and alcohol. Patient does report enjoying watching shows on Netflix and playing video games on her desktop computer at home.
Family Hx:
Mother: arthritis
Father: asthma
Allergies:
Denies allergies to medication or foods. Patient does report seasonal allergies and occasional exacerbations with drastic changes in weather.
Subjective (Review of Symptoms):
Constitutional: denies any unexplained weight loss, chills, fecer
HEENT: denies any headaches, vision changes, decrease in hearing, or sore throat at this time
Cardiovascular: denies chest pain, palpitations, cramping at this time; patient does report that heart feelings like it is racing when patient find herself in large crowds or when she has to do presentations at work
Respiratory: denies shortness of breathing , wheezing, or coughing at this time; patient does report having to take deep breaths prior to presentations at work to calm her self down due to fast breathing
Gastrointestinal: denies dyspepsia, blood in stool, or abdominal pain; denies constipation or diarrhea
Gentiourinary: denies difficulty urinating, frequent urination, or urgency
Musculoskeletal: denies muscle weakness or pain, joint pain/ swelling
Integumentary: denies any abnormal rash, sores or blisters to body
Endocrine: denies any heat or cold intolerance; denies excessive thirst
Hematologic: denies any abnormal bleeding
Neurological: denies any loss of sensation, burning, or tingling
Psychiatric: patient reports mild anxiety and nervousness at this time as there are many people she is unfamiliar with in her surroundings; patient denies depression
Objective (Physical Exam):
Vital Signs:
Wt: 143 lbs Ht: 5 ft 5 inches BMI: 23.8
Constitutional: patient is awake alert and oriented; well-groomed and well-nourished; patient does appear to be a bit nervous, playing with fingers and frequent leg movement; no acute distress noted
HEENT: head is normo-cephalic; hair is well maintained and even throughout scalp; sclera white and conjunctiva pink; PERRLA with EOMs intact; tympanic membranes in both ears are pearly gray with a normal external ear canal; nasal mucosa is moist and pink, no swelling noted to nasal turbinates; teeth in good repair, no cavities noted; oropharynx is pink and moist and negative for any lesions; trachea is midline with no abnormal growths or masses noted to neck
Cardiovascular: no murmurs auscultated; S1,2 noted; no JVD noted; no bruits noted in arteries
Respiratory: all lung fields clear upon auscultation
Gastrointestinal: normoactive bowel sounds; flat, soft, non-tender
Genitourinary: non-palpable bladder, nontender upon palpation
Musculoskeletal: 5/5 strength in all extremities; ROM in all extremities and hip WNL
Integumentary: warm; no lesions noted
Psychological: coherent, thought process normal; patient appears to be slightly nervous with frequent feet and leg movement and playing with fingers and hands during conversation; PHQ-9: 20 and GAD-7: 13
Neurological: all cranial nerves intact when assessed
. In your response to your peer you must include the following: Your top three (3) differentials based on the information provided, the primary diagnosis you are leaning toward, and first line treatment for how you would treat that diagnosis. Use references to support your response.
Post contributes clinically accurate perspectives/insights applicable to the results from the physical exam and diagnoses. Initial post includes the most likely diagnosis/specific treatment plan given case study information supported by rationale and answers all questions presented in the case. Demonstrates course knowledge/assigned readings by: linking tests/interventions accurately to diagnoses, applies learned knowledge specifically to the symptoms and patient information using original dialogue i.e., little to no direct quote.
Discussion post supported by evidence from appropriate sources published within the last five years. Focus of journal articles represents a logical link between the article content and the case study information. In-text citations and full references are provided.
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