Understanding Chief Symptomatology for Diagnosis of Anxiety Obsessive-Compulsive and Trauma and Stressor-Related Disorders

Understanding Chief Symptomatology for Diagnosis of Anxiety Obsessive-Compulsive and Trauma and Stressor-Related Disorders

Subjective:

CC (chief complaint): The case is of a seven-year-old male child presenting with extreme worry. He worries about everything most of the time.

HPI: D.C is a seven-year-old male child brought to the clinic by his mother. The child has been worrying a lot about getting lost and losing his mother and brother. His worries seem to affect his schooling, as he always has trouble at school. Collaborative history from the mother revealed that he is anxious and worried all the time about her mother dying and not being able to pick him up from school. Additionally, he has difficulty getting to sleep and often wants the doors open and lights on as he goes to sleep. He also wakes up from sleep frequently. He also wants to return home from school, citing complaints of stomach aches and headaches. His mother also reported that he doesn’t eat and has lost three pounds in the past three weeks. The client still wets his bed and doesn’t bathe regularly. This has made him be called names at school.

Substance Current Use: The client has a negative history of substance abuse.

Medical History: 

The client has a negative history of hospitalization, head accidents, or injuries.

Current Medications: The client is currently not on any medications and has never used any psychotropic agents.

Allergies: The client has no known allergies.

Reproductive Hx: No reports of maternal pregnancy and birthing complications, as well as drugs and substance use during maternal pregnancy.

ROS:

GENERAL: The client is a seven-year-old male child. He has lost three pounds in the last three weeks.

HEENT: The client has a negative history of head injuries and eye or ear disorders. He denies using any visual and hearing aids. He also has no eye or ear discharge. His vision is intact. He denies having any nasal discharge, congestion, or swelling. Also, no sneezing, discharge, sore throat, or pain during swallowing was reported.

SKIN: No skin lesion, swelling, tenderness, or inflammation reported.

CARDIOVASCULAR: No reports of palpitations, chest pain, chest discomfort, and edema on the extremities.

RESPIRATORY: No reports of shortness of breath, sputum production on cough, and coughing.

GASTROINTESTINAL: No bowel movement inconsistencies were reported. Additionally, there were no reports of melena stool or abdominal pain.

GENITOURINARY: No urinary frequency, urgency, or pain during urination was reported. There were also no reports of urinary discoloration, odor, hesitancy, or polyuria.

NEUROLOGICAL: There were negative reports of syncope, changes in bladder and bowel control, and ataxia. There was also no report of dizziness, seizures, tremors, or weakness in the extremities.

MUSCULOSKELETAL: No reports of joint swelling, tenderness, or limited range of motion on the joints. There were also no reports of joint stiffness and pain.

HEMATOLOGIC: No reports of use of any blood thinners. There were also no reports of bruising, clotting issues, or anemia.

LYMPHATICS: The client has a negative history of lymphatic glandular swelling or splenectomy.

ENDOCRINOLOGIC: There were no reports of excessive sweating or heat and cold intolerance.

Objective:

 Diagnostic results: The clients in the case presented with symptoms suggestive of generalized anxiety disorders. The generalized anxiety disorder 7-item tool (GAD-7) is a self-report diagnostic equipment for screening and assessing the severity of anxiety disorder. These findings can inform the initiation of therapy, the choice of therapy, and how the disorder is responding to medications.

Assessment:

Mental Status Examination:

The client is a seven-year-old male child. He is alert and oriented to the place, time, and event. He is cooperative and responds well to the questions asked. His speech is coherent, clear, and normative intonation and volume. His judgment is intact, logical, and appropriate for his age. He denied having thoughts of self-harm.

Diagnostic Impression: 

The client in the case had generalized anxiety disorder. Generalized anxiety disorder is a mental health disorder prominent in children and adolescents. Pediatric generalized anxiety disorders occur in 10 % of children and adolescents (Mohammadi et al., 2020). It is characterized by symptoms of extreme and unco