Week (enter week #): (Enter assignment title)

Subjective:
CC (chief complaint): The patient complains of extremely worrying about anything
HPI: Cordoba Dev (seven years of age) presents with extreme anxiety and worry. He reports
worrying about everything (death and little love from his mother), having occasional bad dreams,
and being scared of sleeping alone in his room (especially in the dark). He feels lost and worries
all the time about his mother and brother; he feels they might not come to pick him up one day.
He wants to leave school, has lost interest in group activities (including at home), does not take
care of the self, and throws things at others in school (threw the book at Billy) and at home. The
patient also has trouble focusing and concentrating in class, has sleeping difficulty, does not (has
lost 3 pounds in the past 3 weeks), and wets the bed. The patient also complains of stomachaches
and worries about the father.
Substance Current Use: He denies any alcohol/substance use. The patient is only 7 years and
might not have engaged in illicit drug use.
Social History: Dev is the first born in a family of two siblings. He is presently enrolled in an
elementray school but acknowledges disliking it because of mistreatment from teachers and other
students (who call him “smelly”). He has been raised by his mother alone after his father (a
military man) died in war. He seemingly worries about his father and the mother has never told
him the father will never return.
Medical History:
 Current Medications: The patient is taking MDDVAP to prevent bedwetting.
 Allergies: There are no known allergies.

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 Reproductive Hx: He patient has no history of reproductive disorders because he is
sexually inactive (7 years old).
ROS:
 GENERAL: The patient has eating problems (anorexia), is anxious and experiences
recurrent sleeping difficulties, bad dreams, stomaches, and extreme anxiety.
 HEENT: Eyebrows are evenly distributed and symmetrically aligned. Eyes: sclera white,
symmetrical vision, and clear eyesight with no visual loss. Nose, ears, and throat: No
hearing loss, sneezing, sore throat, and flaring/discharge in the nose.
 SKIN: Skin: Ublemished with no foul odor, itching, and rashes. The color of the skin is
also uniform, with no scarring and abnormal skin temperature and turgor. Hair: Appears
silky, thick, short, and evenly distributed. Nails: smooth, light brown, and convex-shaped.
 CARDIOVASCULAR: No chest edema, palpitations, discomfort, pain, and pressure.
Vitals appear normal.
 RESPIRATORY: No wheezing/tight chest, sputum, or cough with mucus. The patient
showed rhythmic, quiet, and effortless respirations.
 GASTROINTESTINAL: The patient reports no diarrhea, nausea, anemia, fatigue, gas
or abdominal pains, bloating, constipation, and change in bowel habits.
 GENITOURINARY: No genital itching and urgency/burning/frequent/recurrent. The
urine is normal with no odd color or odor.
 NEUROLOGICAL: No lack of coordination, memory loss, impaired mental ability,
tingling/loss of feeling, muscle weakness, loss of sensation, paralysis, confusion, and
seizures.

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 MUSCULOSKELETAL: No muscle pain, aching, stiffness, twitches, and burning
sensations.
 HEMATOLOGIC: No frequent infections, excessive bleeding, bruising, and anemia.
 LYMPHATICS: No fluid leaking through the skin, wart-like growths/protrusions on the
skin, and enlarged lymphatic nodes.
 ENDOCRINOLOGIC: No incidences of heat intolerance, cold, polyuria/polydipsia, and
sweating.
Objective:
Physical Exam
Vital Signs: The patient’s vital signs were not taken.
Diagnostic results:
 Use a pychological questionnaire to identify the causes and impacts of anxiety/worry
 Order utine or blood tests to determine source of headache and other physical symptoms
 Order a comprehensive physical examination to determine symptoms/signs linked to the
anxiety
 Use the criteria listed in the DSM-5-TR and ICD-10 Manual
Assessment:
Mental Status Examination:
The patient appears underweight but neat and organized, with a clean-shaven head. He appears to
match his stated age (7 years). His behavior generally can be described as cooperative and
confident (he does not avoid eye contact). He is also relaxed and candid. In terms of speech, the
patient can express himself appropriately (in English) and speaks softly and clearly. Emotionally,
the patient is occasionally anxious, sad, nervous, and angry. His thought process is organized and

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coherent. His cognition is also excellent; he was alert and focused and answered questions
appropriately. He is oriented to time, date, place, and person. The patient is also capable of
concentrating and answering questions correctly. The patient also displays good insight and fair
judgment.
Diagnostic Impression:
I used the DSM-5-TR and ICD-10 guidelines to deduce that the patient (Dev) suffers from
“generalized anxiety disorder.” Based on these guidelines, GAD is characterized by (1) the
presence of extreme worry/anxiety about multiple activities, events, and topics – and the worry
occurs for more than six months, (2) the worry is challenging to regulate/control, (3) and the
worry is accompanied by at least one (for children) of the following cognitive/physical
symptoms, including tiring, restlessness/edginess, impaired concentration, irritability,
soreness/increased muscle aches, and or difficulty sleeping. The term excessive worrying means
worrying even without a specific significant reason (Glasofer, 2022). The patient (Dev) meets
the three criteria above. However, I had to conduct a differential diagnosis to ascertain that the
patient was suffering from GAD and not any other anxiety or panic disorder.
Differential diagnosis:
 Obsessive-compulsive disorder (OCD) – while GAD and OCD are characterized by
excessive anxiety/worrying, the difference between the two is that OCD patients are
obsessive or possess compulsions to cope with anxiety. People with GAD do not.
Common compulsions include repeating word sequences, seeking reassurance, ensuring
order, cleaning, counting, and checking (Citkowska-Kisielewska et al., 2020).
 Panic disorder – The difference between GAD and panic disorder is that the worry in
GAD stems from typical life situations – health, children, job issues, education, finances,

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and family. However, in panic disorder, the worry is spontaneous and/or originates from
when another panic attack will happen. Panic attacks are typified by an unpredicted and
sudden fear that can last a few minutes to peak. Conversely, GAD (or other anxiety
disorders) gradually builds and can take several months. Also, panic attacks accompany
physical clinical manifestations like abdominal distress, heart palpitations, shortness of
breath, and chest pain (The US Department of Health and Human Services, n.d.).
 Social anxiety disorder (SAD) or Social Phobia – GAD differs from ‘social phobia’ in
the sense that the latter is exemplified by excessive self-consciousness and anxiety in
nearly all and strictly social situations, including one-on-one or more minor engagements,
such as performing in front of crowds, being observed, and meeting new people. The
thought content of SAD patients essentially focuses on the negative evaluation and
potential rejection. On the other hand, GAD causes excessive worry or anxiety over
everyday happenings or future events, in and out of social situations (The US Department
of Health and Human Services, n.d.).
Reflections:
If presented with a similar case, one of the things I would do differently is use standard self-
assessment diagnostic tools to assess the causes and severity of the patient’s anxiety and mood; I
will use a different diagnostic tool for Dev and his mother. My subsequent intervention would
also potentially focus on counseling at the school level (school-based therapy) and the family
level (family-based therapy). In school, I would specifically focus on teaching Dev’s teachers
how to handle Dev and control other students better to improve his concentration and school
performance. For family therapy, I would guide the mother on how best to handle Dev’s anxiety,
including the most effective way of telling him about his father’s death. I must also consider in

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my future diagnosis plan the family’s income (economic factors), values and beliefs (cultural
background), religious beliefs, ethnicity/race, and ethical/legal factors to develop a bespoke plan
that meets the needs of the patient and mother. I would also request the mother to provide
consent before interviewing the client because, at 7 years, he is not of the sound age to make
informed decisions.
Case Formulation and Treatment Plan: 
 Recommend psychotherapy [cognitive behavioral therapy (CBT)] by focusing on
assisting the patient in identifying and overcoming (coping) with the causes of anxiety
and worrying positively. For example, the patient can be taught to avoid worrying
thoughts like the father never returning by focusing on exercise and school work. CBT
primarily focuses on situations, thoughts, emotions, physical feelings, and potential
actions (Gerlach & Gloster, 2020)
 Continue MDDVAP daily at bedtme.
 Start the patient on 30 mg per day for two weeks.
 Recommend alternative therapies like exercise, good nutrition, and traditional medicine
(herbs).
 Recommend mind-body techniques like progressive/continuous hypnosis, meditation,
diaphragmatic breathing, and muscle relaxation (Baric et al., 2018)
 Follow up after a week to monitor whether the signs/symptoms are receding or
aggravating for potential therapy withdrawal or change and to confirm whether the
patient follows the prescribed regimen (pharmacologic and nonpharmacologic).
 Refer the patient to a nutritionist to manage his weight

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 For health promotion, give the patient brochures (images) containing information about
coping with stress and the benefits of living a stress-free and happy life.
 Conduct a one-on-one education on compliance and medication

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References

Baric, H., Dordevic, V., Cerovecki, I., & Trkulja, V. (2018). Complementary and alternative
medicine treatments for generalized anxiety disorder: Systematic review and meta-
analysis of randomized controlled trials. Advances in Therapy, 35, 261-288.
Citkowska-Kisielewska, A. (2020). Obsessive-compulsive symptoms in obsessive-compulsive
disorder and in generalized anxiety disorder: Occurrence and correlations. Journal of
Psychiatric Practice, 26(2), 101-119. doi: 10.1097/PRA.0000000000000451
Gerlach, A., & Gloster, A. (2020). Generalized anxiety disorder and worrying: A comprehensive
handbook for clinicians and researchers. John Wiley & Sons.
Glasofer, D. R. (2022, July 25). Generalized anxiety disorder: Symptoms and DSM-5 diagnosis.
Very Well Mind. https://www.verywellmind.com/dsm-5-criteria-for-generalized-anxiety-
disorder-1393147
The US Department of Health and Human Services. (n.d.). What are the five major types of
anxiety disorders? https://www.hhs.gov/answers/mental-health-and-substance-
abuse/what-are-the-five-major-types-of-anxiety-disorders/index.html