Subjective
‘I’ve come to visit you because my mother told me that you could help me.’
HPI;
He is a 7-year-old African American child who was brought to the clinic by his pediatrician and accompanied by his mother, who is in the room with him at all times He said that he is constantly nervous and that nothing calms him down. Even more disturbing, he’s been experiencing a lot of nightmares about losing his mother and sibling, and they happen virtually daily. It was reported by him that he doesn’t like to sleep in a dark room, therefore his mother always keeps the lights on and the door open to let him know she is nearby (Kodish, 2022). He confessed that he worries about his mother and brother a lot while he’s at school, and wondered if they were okay. Mr. Smelly is the name he gets at school because he doesn’t bathe and wets his bed, and this makes him feel terrible, he says.
Substance Current Use:
No illegal substances, alcohol, or cigarettes have been used by the patient.
Medical History:
Current Medications: Synthroid 75 mcg with Zoloft 100 mg
Allergies; Medication:none
No food.
There is no record of rhinitis, asthma, eczema, or hives in the family.
Reproductive Hx:
PMHx: Vaccination for tetanus was administered on December 7, 2018.
ROS:
GENERAL: Fatigue, loss of energy, lack of chills or fever
HEENT: No sneeze, no sneezing, no running nose, no hearing loss, and no sore throat from the nose, ears, and throat.
No blurred vision, no vision loss, no yellow sclerae, and no double vision are present in the eyes of the patient.
SKIN; A complete absence of rashes and itching.
CARDIOVASCULAR: No discomfort or soreness in the chest, no edema, and no palpitations were experienced.
RESPIRATORY: There is no sputum, no difficulty breathing, and no coughing in this situation.
GASTROINTESTINAL: There was no constipation, starvation, nausea, nausea, blood in the stool, or stomach problems.
GENITOURINARY: During urination, there’s no stinging or burning.
Five days ago was my last menstrual cycle.
NEUROLOGICAL: Symptoms like tingling or numbness in the limbs, dizziness or ataxia, headache, paralysis or changes in the way one manages one’s urine or bowels are absent.
MUSCULOSKELETAL: There is no stiffness or soreness in the back or joints.
HEMATOLOGIC: Brusing, hemorrhage or anemia are not present.
LYMPHATICS: No splenectomy was performed, and there were no swollen lymph nodes to speak of.
ENDOCRINOLOGIC: Temperature intolerance, sweating, fluid retention, polyuria are not present in the patient at this time.
Objective:
Heart; the patient’s heart rate is 70 BPM, there are no gallops, RRR, or murmurs in the arteries.
Vitals; the patient has a 120/80 mmHg blood pressure and a fever of 100.2 degrees.
General observation: It’s safe to say that the patient is awake and aware. All questions are answered in a timely manner by him. She is in a bad mood and in a state of extreme anxiety. Stable balance and a normal walking pattern.
Skin; the skin was clear of rashes and blemishes.
Lungs; CTA on each sides
Lab: A normal TSH, CBC, and lytes.
Diagnostic results: During the assessment, it was discovered that the patient was unable to focus and maintain the attention. The findings of the other tests were all normal.
Assessment:
Mental Status Examination:
Young African American boy who appears to be the claimed age, is properly attired for the weather, is well-groomed, and is in good nutritional health is the subject of this investigation. There are no anomalous motor movements, yet he is cooperative with poor eye contact. Comprehensible words in the correct volume and tone with flat facial expressions are all characteristics of his demeanor at this time. It was determined that he did not have any hallucinations, delusions, or other signs of paranoia during the course of the examinations that were conducted on him (Cobham, 2020). Although he is awake and aware of the present moment, he is only vaguely aware of the nature of his disease. His memory and intellect are intact, but he is only vaguely aware of the nature of his condition.
Differential diagnosis:
Pediatric separation anxiety disorder
Oppositional defiant disorder
Anxiety behaviors
Primary diagnosis: Pediatric separation anxiety disorder
Reflections: D.C.’s diagnosis of separation anxiety disorder seems correct based on the data and mental exam. I learned that separation anxiety disorder is the most frequent child anxiety issue. In this case study, I could have built a better relationship with DC before evaluating the mother and child. Misdiagnosis, treatment compliance, conflicts of interest, and secrecy are ethical issues. Separation anxiety disorder can be averted by practicing short goodbyes, practicing leaving, avoiding rewarding fear, and keeping a familiar environment.
Case Formulation and Treatment Plan:
The goal of treating children with separation anxiety is to get them back to their usual selves (Ströhle, 2018). Therapy, medication, and relaxation techniques all play a role in treatment. As a result, D.C. will begin counseling, learn relaxation techniques, and begin taking fluoxetine 10 mg daily.
Follow up after one month of non-pharmacological therapy
The recommendation of a therapist for cognitive behavioral therapy
Recommendation of an educational group.
References
Ströhle, A., Gensichen, J., & Domschke, K. (2018). The diagnosis and treatment of anxiety disorders. Deutsches Ärzteblatt International, 115(37), 611.
Cobham, V. E., Hickling, A., Kimball, H., Thomas, H. J., Scott, J. G., & Middeldorp, C. M. (2020). Systematic review: anxiety in children and adolescents with chronic medical conditions. Journal of the American Academy of Child & Adolescent Psychiatry, 59(5), 595-618.
Kodish, I., Rockhill, C., & Varley, C. (2022). Pharmacotherapy for anxiety disorders in children and adolescents. Dialogues in clinical neuroscience.
