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This clinical case study examines Susan, a 45-year-old female, experiencing insomnia after a hysterectomy and stopping hormone replacement therapy (HRT). It details her subjective information, medical/psychiatric history, and objective assessment (vital signs, diagnostics, mental status). Insomnia disorder is diagnosed, with differential diagnoses of generalized anxiety and adjustment disorder. The treatment plan includes cognitive behavioral therapy, sleep hygiene, medication, and lifestyle changes. This study offers insights into diagnosing and treating insomnia and related anxiety, emphasizing psychological and physiological factors for holistic patient wellness. DSM-5 criteria and references are included.
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Criteria Clinical Notes Subjective Patient information: Susan 45 - year-old Caucasian female. Include chief CC :^ “I’ve^ been^ having^ trouble^ sleeping” complaint, subjective HPI : information from the Susan is a 45 - year-old Caucasian female who visited the clinic with patient, names and complaints of sleep disturbances for last three months. She recently relations of others underwent a hysterectomy due to uterine fibroids. Her OBGYN present in the physician, Dr. Ferris, prescribed hormone replace therapy (HRT) but interview, and basic patient, after doing some of her own research, decided to demographic discontinue treatment because of concerns about potential cancer information of the risks, especially due to her mother’s history of cancer. After her patient. HPI, Past decision to stop HRT, Susan had experienced sleeping disturbances Medical and such as tossing and turning, inability to achieve deep sleep, and Psychiatric History, sleeping only 2 - 3 hours per night. She reported feeling anxious and Social History. desperate to sleep, and increase in stress levels due to her inability to focus during the day on her work. Susan reported that her job performance is negatively impacted by her lack of sleep, and also social interactions with her friends. She stated that she needs to take naps during the day whenever possible, and that disrupts her daily life and schedule. Also, reported that over-the-counter sleep aids are not helping much. Past Psychiatric History General statement: Denies history of mental illness. Caregiver: none Hospitalizations: none Allergies: NKDA Medications: D.C. does not currently take any medication. Was prescribed HRT but does not take anymore. Pychotherapy or prior psychiatric diagnosis: Denies. Substance abuse history : patient denies taking any drugs or smoking, or drinking alcohol. Family Psychiatric history : Mother was diagnosed with GAD after her cancer diagnosis. Denies any suicides, or any other known psychiatric conditions in the family. Social history : Susan is a freelance writer for a local paper. She is married to Mark and live in Seattle. She had friends and a social life but since her sleep problems, she avoids going out and cancels a lot of her plans to accommodate her need for sleep such as taking naps during the day. Medical History : History of benign uterine fibroids, recent
hysterectomy. ROS General: Denies chills, fatigue, or recent weight changes. HEENT: Head – denies headaches, or lightheadness, or trauma. Eye – denies blurry vision, or photophobia or pain. Ear – denies pain or discharge, or hearing loss. Nose and Throat: denies any pain/soreness or other issues. Skin: denies jaundice, itchiness, or rashes. Cardiovascular: Reports palpitations, chest thightness, and shortness of breath. Denies any edema, or heart murmurs. Respiratory: Denies cough, wheezing, or dyspnea. GI: Denies N/V/D/C. Denies acid reflux. Neurological: Denies numbness, tingling, headaches, dizziness, or syncope. Objective ROS: see above Objective data Vital Signs BP: 121/76 HR: 76 RR: 18 SPO2: 97% T: 98. Pain: 0/ Height: 5’5 Weight: 130 BMI: 21.6 normal Diagnostic results : GAD- 7 : score 10, which indicates moderate anxiety Thyroid function test, CBC, CMP, Troponin: Normal Toxicology screening: negative BAC level: normal ECG: Normal Mental status examination He is a 45-year-old Caucasian female who is in dressed appropriately, has a clean appearance, and seems her stated age. She appeared hesitant at first but starts cooperating during the interview. Appeared anxious, and restless but speech was clear, coherent, and of a normal volume and tone. Affect is congruent with mood when discussing her sleep issues. Susan had a logical thought process, and made clear connections between her inability to sleep, fears and worries regarding her family history of cancer. Her judgment is compromised because of her fears and health concerns, evidenced by her stopping HRT despite Dr. Ferris’ recommendations. Susan denied delusions, visual or auditory hallucinations, or suicidal thoughts. She is alert and oriented x4, and in control of this thoughts and actions. Cognitive function might be impaired due to fatigue. She has intact memory, and her understanding of her situation is average. This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results. Assessment Diagnosis
References: American Psychiatric Association. (2022). Diagnostic and statistical Manual of Mental Disorders, text revision (5th ed.). American Psychiatric Association. Carlat, D. (2017). The psychiatric interview (4th ed.). Philadelphia Wolters Kluwer. Gottschalk, M. G., & Domschke, K. (2017). Genetics of generalized anxiety disorder and related traits. Dialogues in clinical neuroscience , 19 (2), 159–168. https://doi.org/10.31887/DCNS.2017.19.2/kdomschke