Discuss relevant pharmacological agents and supportive treatments b. Are there any incidences of antimicrobial resistance?

Group Members: Cierra Coleman, Jenny Pierre, Rachael Ruetz

Reason for Visit

Source of Referral: PCP

Chief Complaint: “I’ve been feeling very anxious and having panic attacks a few times a week.’’

History of Present Illness:

Discuss relevant pharmacological agents and supportive treatments b. Are there any incidences of antimicrobial resistance?. She reports experiencing daily generalized anxiety for several years, with panic attacks occurring 2–3 times weekly, described as sudden episodes of intense fear, heart racing, and shortness of breath. She endorses difficulty falling asleep and frequent nighttime awakenings, for which she takes lorazepam 0.5 mg, currently using it 1–2 times daily. She also occasionally uses over-the-counter melatonin without consistent benefit.

Linda describes persistent fatigue, hopelessness, and poor concentration over the past six months but denies current suicidal ideation, anhedonia, or feelings of worthlessness. She endorses feelings of loneliness and reports limited social support, noting distant relationships with her adult children and minimal interaction with others. Psychiatric history includes a previous trial of escitalopram five years ago, which she discontinued due to GI upset and emotional blunting. She briefly attended CBT six years ago for anxiety but discontinued after six sessions, stating it was not helpful at the time. She has no prior psychiatric hospitalizations or suicide attempts but admits to being dependent on lorazepam. She denies current alcohol or drug misuse but consumes 2–3 cups of coffee daily and drinks 1–2 glasses of wine weekly.

Linda expresses interest in treatment but appears ambivalent about restarting medications due to past side effects and a sense of discouragement. She is seeking help primarily to reduce her anxiety, improve her sleep, and regain a sense of emotional stability.

Review of Systems

Psychiatric and Medical Review of Systems:

· Mania: Denies periods of elevated mood, decreased need for sleep, increased goal-directed activity, or impulsivity.

· Depression: Endorses occasional feelings of hopelessness and fatigue but denies crying spells, suicidal or homicidal ideation, worthlessness, or anhedonia.

· Anxiety/Panic: Endorses daily generalized anxiety and panic attacks 2–3 times weekly.

· Obsessions/Compulsions: Denies intrusive thoughts or repetitive behaviors.

· Trauma: Endorses witnessing domestic violence in her childhood home. Denies sexual assault or military trauma.

· Psychosis: Denies hallucinations, delusions, or paranoia.

· Memory/Concentration: Reports poor concentration and forgetfulness over the past six months.

· Sleep: Reports difficulty falling asleep and waking multiple times nightly. Uses lorazepam nightly to initiate sleep.

· Appetite: Endorses normal appetite; denies weight change.

Medical Systems Review:

· Neurological: Denies seizures, headaches, or dizziness.

· Cardiovascular: Denies chest pain or palpitations outside of anxiety episodes.

· Respiratory: Denies shortness of breath or cough.

· Gastrointestinal (GI): Reports occasional constipation; denies abdominal pain, nausea, or vomiting.

· Genitourinary (GU): Denies urinary frequency, urgency, or incontinence.

· Pain: Reports occasional back pain due to a prior car accident but denies chronic pain requiring medication.

Current Medications

· Lorazepam 0.5 mg PO PRN (current use: 1-2 times daily)

· Multivitamin daily

· Over-the-counter melatonin 5 mg PRN for sleep

Psychiatric History

· Medications: Previously trialed escitalopram five years ago but discontinued due to reported GI upset and "feeling numb." No other antidepressants or mood stabilizers trialed.

· Hospitalizations: None.

· Counseling/Therapy: Attended cognitive behavioral therapy (CBT) briefly six years ago for approximately six sessions but discontinued due to "not feeling it helped."

· Suicide Attempts: Denies past suicide attempts.

· Substance Use: Denies history of recreational drug use. Occasional alcohol use (1–2 glasses of wine per week). Admits to dependency on prescribed lorazepam.

Medical History

· Illness/Injuries: Diagnosed with hypertension five years ago, managed with lifestyle modification. No history of diabetes or chronic illness.

· Surgeries: Appendectomy at age 23. C-section at age 30.

· Allergies: NKDA (No Known Drug Allergies).

· Pregnancy/Contraception: Two children (ages 23 and 19). Not currently sexually active. Post-menopausal.

Habits

· Alcohol: Occasional (1–2 drinks per week), denies binge drinking.

· Drugs: Denies illicit drug use.

· Caffeine: Consumes 2–3 cups of coffee daily.

· Tobacco: Former smoker, quit 10 years ago; smoked for 15 years.

· Supplements: Takes OTC melatonin and a multivitamin.

Family Psychiatric History

· Mother: Diagnosed with generalized anxiety disorder, treated with diazepam for several years.

· Father: History of alcohol abuse and domestic violence. Died of liver cirrhosis.

· Maternal grandmother: Died by suicide at age 67.

· Brother: Diagnosed with depression and has a history of cannabis use.

Psychosocial History

· Developmental and Educational History:

Linda was born full-term via normal vaginal delivery. No reported developmental delays. She reports being a quiet child who “worries a lot.” She completed high school and earned an associate degree in office administration. Reports no learning disabilities.

· Current Family:

Divorced, lives alone. Two adult children who live out of state. Limited contact with ex-husband. Describes relationships with children as “distant but civil.” States she feels “very alone” much of the time.

· Social Supports/Faith:

Minimal social support. Occasional phone calls with an old college friend. No current involvement in community groups or religious organizations. Raised Catholic but does not currently practice.

· Adverse Life Events:

Reports of an emotionally abusive marriage lasting 18 years. Divorced 8 years ago. Also reports a traumatic car accident 7 years ago, resulting in mild concussion and chronic back pain. Childhood marked by witnessing father’s alcohol abuse and parental conflict.

OBJECTIVE MENTAL STATUS EXAMINATION: Appearance: Appropriately dressed and groomed. Appears restless, fidgeting with nails while answering questions. Maintains good posture and appropriate eye contact. Orientation: Alert and oriented to person, place, time and situation. Concentration: Concentration slightly impaired due to patient having difficulty performing serial 7’s. Manner: Cooperative and engaged. Speech: Normal tone, rate and rhythm. Mood: Patient reports feeling anxious, hopeless and fatigued. Affect: The patient's affect is congruent to their reported mood. Thought Process: Thought process is goal directed and logical. Thought Content: The patient reports feeling anxious and unable to control her anxiety. She reports feeling episodes of intense fear, shortness of breath and tachycardia that impacts her daily life. The patient also states she struggles with difficulty falling asleep and waking up multiple times in the night. Perceptions: The patient denies hallucinations, delusions and illusions Memory and Cognition: Short and long-term memory intact. Immediate memory impaired, patient unable to recall 1 out of the 3 items during the three-item recall test. Judgment: Judgement is intact due to the patient seeking medical help for her conditions. Insight: The patient displayed insight regarding the nature of their condition.

Collateral Information: *** Suicide assessment and treatment planning will be completed in future assignments.

Comprehensive Suicide Evaluation

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