In Weeks 4, 7, and 9 of the course, you will participate in clinical discussions called grand rounds. In one of these three weeks, you will be a presenter as well as help facilitate the online discussion

Expert Answer and Explanation

Subjective:

CC (chief complaint): “I have difficulty falling asleep, am always sad, and am easily distracted.’

HPI: The patient is a 26-year-old female who presented to the office complaining of anxiety, depression, and insomnia. The patient notes that she has been having problems with falling asleep, is easily distracted, is always sad, and has difficulties completing tasks. The patient also complains that she has trouble wanting to see people and associating with people.

The patient notes that she finds comfort in isolating herself. She reports anhedonia and cried during the interview. She also reports severe anxiety. She says that her anxiety became more severe when she had that the person who raped her was released from jail. The symptoms have negatively affected her life. Her therapist pulled her out of work, and she hardly made friends with people. She rates her anxiety and depression as 8/10.

Substance Current Use: She reports no current use of illicit drugs.

Medical History: The patient has no medical problems.

• Current Medications: She is not on any medications at the moment.
• Allergies: She reports no allergies.
• Reproductive Hx: No reproductive problems.

ROS:

• GENERAL: She denies fatigue, weight loss, chills, or fever.
• HEENT: Eyes: No yellow sclerae, visual loss, or double vision. Ears, Nose, Throat: No hearing problems, runny nose, congestion, sore throat, or sneezing.
• SKIN: No rash or itching.
• CARDIOVASCULAR: No chest pain, edema, chest discomfort, or palpitations.
• RESPIRATORY: No shortness of breath.
• GASTROINTESTINAL: No diarrhea, vomiting, abdominal blood, or pain.
• GENITOURINARY: She reports no odd urine color, no odor of urine, or burning on urination.
• NEUROLOGICAL: No dizziness, headache, syncope, ataxia, paralysis, numbness, or tingling in the extremities.
• MUSCULOSKELETAL: No joint or muscle stiffness or pain.
• HEMATOLOGIC: No anemia, HIV, bleeding, or bruising.
• LYMPHATICS: No enlarged nodes.
• ENDOCRINOLOGIC: No reports of health intolerance, cold, or sweating abnormities.

Objective:

Vital Signs: BP 102/90, P 67, RR 17, Ht. 5’4″, Wt. 67kgs, Temp 36.5.

Physical Exam 

• HEENT: Noncontributory.
• Skin: No rash or itching.
• Cardiovascular: Regular heart rhythm and heart rate. No cracks on the chest walls. No edema.
• Respiratory: Normal breathing sounds, no wheezing, no fluids in the lungs, crackles, and no inspiratory crackles.

Diagnostic results:

1. Beck Anxiety Inventory (BAI): Lemos et al. (2019) noted that BAI is used to measure the severity of patients’ anxiety. The authors found that the tool’s reliability is (Cronbach’s α=0.92) in terms of internal consistency. The patient scored 37, meaning that she has severe anxiety.
2. Beck’s Depression Inventory (BDI): BID is a screening tool used to screen for depression (García-Batista et al., 2018). The patient scored 23, meaning that she has moderate depression.

Assessment:

Mental Status Examination: 

The patient is well-dressed, and her clothing is consistent with the day’s weather. She was well-behaved during the interview. However, she was crying while answering questions. She maintained eye contact during the interview. She reports sadness and affect consistent with her mood. Her speech is intact. She denies hallucinations, delusions, suicidal thoughts, or homicidal thoughts. Her memory is intact. Through process is also intact.

Diagnostic Impression:

1. Generalized Anxiety Disorder (GAD) DSM-5 300.02 (F41. 1)
2. Mood disorder, ICD 10 Code: F33.2 – Major Depressive Disorder, Severe, Recurrent
3. Insomnia Disorder DSM-5 780.52 (G47.00)

The primary diagnosis for this case is GAD. According to Price et al. (2019), GAD is associated with extreme anxiety, which cannot be controlled easily. The anxiety must be characterized by a