Health Diagnosis

Mr. J is a 35-year-old male with a history of anxiety for 10+ years. He was taking Lexapro 20 mg per day for anxiety but was switched to Trintellix 10 mg a year ago due to sexual side effects and weight gain. He reports that over the past 3 months his anxiety has worsened. He feels restless and paces. He has been worrying more. He has not been able to focus and concentrate. He has ruminating thoughts and finds it hard to shut his mind off. He has noticed an increase in shoulder pain and headaches. He has been eating less due to GI upset. He reports losing weight. His weight at his last visit was 165 pounds at 5’ 11”, and is 150 pounds today. He also reports panic attacks, which are occurring at least once a week. During the panic attacks, he is short of breath, has palpitations, shakiness and sweats. They last 5-15 minutes. When the panic attack resolves, he feels exhausted. His temp is 98.6 pulse 98, and BP 140/90. He appears anxious and speaks rapidly. You note psychomotor restlessness with wringing hands and shaking his leg. His eyes, nose, and throat are normal. Mr. J has been married for five years and has 3-year-old twin boys. He and his wife own their home. He works as an IT manager for a local Internet company. He had a T& A at 10 years of age. He drinks (2) Energy drinks a day and along with 32 ounces of sweet tea. He denies ETOH use. He denies tobacco use. He smokes marijuana at least once a week “to relax”. He takes Tylenol and Advil as needed for pain. His PCP has prescribed Baclofen for shoulder pain and headaches. He reports bouts of diarrhea at least once a week for the past month. He notes mild nausea but denies vomiting. He bikes at least 5 miles four days a week. He has never been hospitalized for psychiatric reasons and denies suicide attempts and self-mutilating behaviors.

Instructions

• Pt name, age, chief complaint, major pertinent diagnoses
• Subjective data: to include pertinent other history factors, such as recent hospitalizations, pertinent immunization history. You will be adding diagnostic testing and rationale, so in order to keep your recording under 4 minutes, you will need to omit information that is not relevant.
• Objective data: Physical exam findings
• Differential diagnoses (minimum of 3 for this presentation; you will not need that many for every patient in the clinical setting)
• Reasons for choosing those, and which one you believe most likely with rationale
• Questions for preceptor/faculty about the case or the diagnosis
• Plan: what will be what diagnostic tests you recommend, if any, and why, with some mention of cost vs. benefit.
• Further learning you feel you need related to this case.
• Reference(s) used in developing your differential and the diagnostic test recommendations