MENTAL HEALTH TREATMENT PLAN/ANALYSIS
Running head: MENTAL HEALTH TREATMENT PLAN/ANALYSIS 1
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Running head: MENTAL HEALTH TREATMENT PLAN/ANALYSIS
Mental Health Final Treatment Plan/Analysis
NR 603
Assessment: Generalized anxiety disorder (F41.1)
R.W. is 58-year-old Caucasian female with symptoms of increased anxiety for 1 week associated with shakiness, body tension and a “wound up” feeling upon awakening, impacting her work and daily life, likely complicated by many stressors, denying any specific triggers. Patient does not report symptoms of long periods of sadness, suicidal or homicidal ideation or hallucination. At this time, it is most suggestive of generalized anxiety disorder, meeting the diagnostic criteria, however underlying medical conditions are considered.
Plan:
1.Generalied anxiety disorder- Sertraline 25 mg PO daily, Dis 30, Refill: 0
Symptomatic improvement may not be seen for a few weeks, avoid abrupt discontinuation of medication, report worsening: depression, suicidal ideation, or unusual changes in behavior, avoid alcohol/caffeine, continue meditation and relaxation techniques (meditation, yoga, deep breathing and visualization techniques) engage in daily physical activity, healthy balanced diet, cognitive behavior therapy
2. Insomnia: recommend OTC melatonin
Make sleep a priority, routine sleeping patterns
Follow up in 1 week, instructed to return to office if symptoms of anxiety worsen or do do improve. If any thoughts of suicidal ideation or level of threat to self or others, then seek medical attention immediately.
Referral to psychology for cognitive behavior therapy
Analysis Pathophysiology and Pharmacology: For the primary diagnoses in the case, write a brief summary of the underlying pathophysiology and tie pharmacological treatment chosen in the reversal or control of that pathology.
The etiology of GAD is unknown. An underlying theme to several models is the dysregulation of worry. Evidence suggests that patients with GAD may experience persistent activation of areas of the brain associated with mental activity and introspective thinking following worry-inducing stimuli (Locke, Kirst, & Shultz, 2015). It is likely the result of a combination of biologic abnormalities, such as decreased metabolic rate in the basal ganglia and white matter, abnormal serotonergic and noradrenergic neurotransmission, and also psychosocial factors (Oji, & Heering, 2018). Twin studies suggest that environmental and genetic factors are likely involved.
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line therapy for GAD. Psychotherapy, such as cognitive behavior therapy can be as effective as medication for GAD and has the best level of evidence. Studies suggest that combining medication and psychotherapy may be more effective for patients with moderate to severe symptoms (Locke, Kirst, & Shultz, 2015).
Additional analysis of the case: This includes national guidelines that were or should have been used to make diagnosis or treatment and review how they applied or how care was unique but based in guidelines.
The diagnosis and treatment used for this case was based on the DSM-5 diagnostic criteria for GAD:
1. Excessive anxiety and worry occurs more days than not for at least 6 month affecting events or activities. R.W. has been experiencing symptoms of anxiety for the past 2 years.
2. The individual finds it difficult to control worry. Her symptoms have been increasing for 1 week.
3. The anxiety and worry are associated with three or more of the following symptoms, restlessness, easily fatigued, difficulty concentrating or mild blanking, irritability, muscle tension, and sleep disturbances. She complains of insomnia, body tension, and irritability.
4. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The anxiety has been impacting her daily life and work.
5. The disturbance is not attributable to the physiological effects of a substance (drug abuse or medication) or another medical condition. Denies smoking, ilicit drugs, alcohol use, other medications, hypothyroidism was ruled out.
6. The disturbance is not better explained by another medical disorder (American Psychiatric Association, 2013).
Follow-up: This means how the patient was doing when seen a second time if this applies. This would be their response to your plan of care.
During a second time visit in 1 week, I would expect for R.W. to be on the path of reporting having decreased anxiety symptoms and better sleeping patterns. Sertraline relieves anxiety symptoms and helps reduce the symptoms of depression that often accompany anxiety disorders, though it may take some weeks to start working. If insomnia and GERD symptoms are still reported then there will be a need for further evaluation. I would also expect compliance with the treatment plan taking medications as prescribed and following up with the psychologist for cognitive behavioral therapy.
Quality: Include anything that should have been considered in hindsight or changes you would make in seeing similar patients in the future with the same complaint, history, exam, or diagnosis. Add anything you learned from discussion in the class that shed new light on this patient.
I would preform a more thorough personal and family medical and mental health history in the future. I would order a CBC and CMP in addition to the TSH to rule out medical conditions. In addition to the EKG, I would order pulmonary function testing to rule out any pulmonary conditions related to her intermittent shortness of breath (Oji, & Heering, 2018). I learned that GAD is recognized when signs and symptoms of muscle tension, fatigue, sleep disturbance, poor concentration, irritability, and restlessness for four or more days a week for 6 months, cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. It is not related to the use of a substance, such as an illicit drug, or medication, the presence of a medical condition, such as an acute myocardial infarction, asthma, headaches, anemia, caffeine intoxication, hypoglycemia, hyperthyroidism, substance intoxication/withdrawal, and complex partial seizures, or the presence of another mental disorder such as panic attacks, post-traumatic stress disorder, major depressive disorder, psychotic disorder, pervasive developmental disorder, social phobia, obsessive-compulsive disorder, separation-anxiety disorder (Oji, & Heering, 2018).
Coding and Billing. Any or all CPT and ICD-10 codes that should have been used (List them and name them only.
99214 Established patient moderate to high complexity
93005 EKG
Z00.01 Encounter for general adult medical examination with abnormal findings
F41.1 Generalized anxiety disorder
R00.2 Palpitations
F41.8 Other specified anxiety disorders
G47.00 Insomnia
Reference
American Psychiatric Association. (2013). Generalized anxiety disorder. Retrieved from https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_GeneralizedAnxietyDisorder.pdf
Locke, A. M., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder. American Family Physician. Retrieved from https://www.aafp.org/afp/2015/0501/p617.html
Oji, O. D. A. F. B., & Heering, H. R. C. (2018). Generalized anxiety disorder. CINAHL Nursing Guide.
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