Mildred is a 45-y.o. married female with three children. She presents to you with complaints of fatigue and difficulties sleeping. She states she wants to get a good night’s sleep and is requesting a prescription to help her sleep. Mildred tells you she is awake off and on during the night, frequently thinking about her husband’s recent layoff from construction work and the effect this is having on the family. She lies down often during the day and has been so fatigued that she took some time off from work during the last 2 weeks. She is tearful at times during the visit and looks sad and anxious. On further discussion, she says she feels overwhelmed, helpless, and anxious. She tells you about an episode where she felt her heart beating rapidly, had difficulty catching her breath, felt she was going to have a heart attack, and became frightened until her husband was able to help calm her down. She is not eating as much as usual, and when she reads the newspaper, she doesn’t remember what she has read.
What would your focused clinical assessment include?
What are your initial differential diagnoses?
What major psychological question needs to be addressed?
What testing would you order to rule out any medical problems?
What is your plan of care?
What are the mainstays of treatment?What is your initial follow up plan?
What education would you provide to your patient?