Week 6: Mental Health Clinical Presentation Part 1
Dr. Julian and Classmates,
Please see the following for my case study for this week which was based off a patient I had seen
in the clinic in one of my first clinical
...
Week 6: Mental Health Clinical Presentation Part 1
Dr. Julian and Classmates,
Please see the following for my case study for this week which was based off a patient I had seen
in the clinic in one of my first clinical rotations. I would normally have done some routine lab work for
the patient to rule out other possible physical causes that could contribute to the patient’s symptoms;
however, in this particular situation my preceptor felt confident on not doing them at the initial visit and
opt to do it at one of the follow up appointments in the next six months if the patient was to return back
to the clinic.
Setting: Primary Care Office
Patient Information: A.B., 22-year-old Caucasian Male
Subjective
CC: “Unable to leave my house.”
HPI: A.B. is a 22-year-old Caucasian male that presents to the clinic today with complaints of anxiety-like
symptoms and fearfulness of interacting with people in social gatherings and at work. He states he feels
nervous and fearful and can feel his heart racing when he has to leave his house to attend work
meetings. Onset of symptoms was 7 months ago after he graduated from online college and started his
first job post-college using his degree in business. Prior to this, the patient states he was never really
social and usually kept to himself growing up. He states he had one to two close friends growing up but
he never partake in usual friendly gatherings at school or in the community, but also never had anxiety
like this before. At his current job he has to attend required meetings with his boss and coworkers that
usually have 20 to 30 people present for hours at a time. Sometimes he has to speak in these meetings
which increases his anxiety of the whole situation. A.B. states he only feels anxious and fearful when he
goes to work every day and once he is home, he feels like himself again and is able to finally “breathe
and relax”. A.B. states that he begins to feel anxious and fearful anytime he has to initiate a conversation
with others at work and that is when he starts to excessively sweat all over, his heart feels as though it is
racing fast and he has trouble collecting his thoughts. He has missed work and meetings due to his
symptoms and he now fears he might lose his job because of this. He states he has tried yoga,
meditation, positive reflection and thinking but none have worked or lessened his symptoms. He has not
tried any medications but is willing to do whatever it takes to ‘feel normal again’ and to not lose his job.
Current Medications: No current medications.
Allergies: NKDA
PMHx and PSHx: No chronic illnesses, no recent hospitalizations or surgeries, all vaccines and
immunizations are up-to-date. Patient has had the chicken pox as a child.
Health Screening: Patient has a routine physical annually with last one being one year ago in November
2018
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