Maria Lopez Case Study: Clinical Management of Generalized Anxiety Disorder

Patient Name: Maria Lopez.
Age: $34\text{ years old}$ .
Gender: Female.
Ethnicity: Hispanic.
Occupation: Elementary school teacher.
Marital Status: Married.
Living Situation: Lives with husband and two children, ages $6$ and $4$ .
Chief Complaint: "I just feel constantly anxious and on edge. I can't relax anymore."

Duration: The patient reports worsening anxiety for the past $6\text{ months}$ .
Symptom Characteristics:
- Characterized by excessive worry occurring nearly every day.
- Associated symptoms include restlessness, fatigue, muscle tension, difficulty concentrating, and insomnia (difficulty falling or staying asleep).
Triggers: The patient cannot pinpoint anything specific in her life causing the anxiety; there are no new significant life stressors.
Impact on Functioning: Symptoms interfere significantly with both work and family life.
Review of Systems (Constitutional/Psychiatric):
- Positive findings: Anxiety, fatigue, muscle tension, and insomnia.
- Negative findings: Denial of panic attacks, suicidal ideation (SI), homicidal ideation (HI), hallucinations, and delusions.
- Negative for weight loss, chest pain, and shortness of breath.
- Psychosomatic considerations: The patient denies heart palpitations, tingling in hands, or shortness of breath (symptoms typically indicative of panic).

Generalized Anxiety Disorder-7 (GAD-7): The patient scored $15$ .
Patient Health Questionnaire-9 (PHQ-9): The patient scored $6$ .
Interpretation: A score of $15$ on the GAD-7 suggests severe anxiety. A score of $6$ on the PHQ-9 suggests mild depressive symptoms, which often overlap with anxiety disorders.

Past Medical History (PMH): Significant for hypothyroidism.
Current Medications:
- Levothyroxine: $75\,\mu g$ daily.
- Multivitamin: Once daily.
Allergies: No known medication allergies.
Family History:
- Mother: History of depression.
- Sister: History of anxiety.
Social History:
- Alcohol Use: Drinks $2\text{ glasses of wine}$ on weekends.
- Tobacco/Illicit Drug Use: Denies use.
- Exercise: Currently does not exercise.
- Safety: Feels safe at home.

Generalized Anxiety Disorder (GAD): Primary diagnosis based on the persistence and nature of symptoms for over $6\text{ months}$ .
Panic Disorder: Considered due to psychosomatic complaints common in anxiety, though ruled out by the patient's denial of specific panic attack symptoms.
Hypothyroidism/Hyperthyroidism (Medication-Induced): Investigating if current levothyroxine levels are too high, causing iatrogenic hyperthyroidism (anxiety-mimicking symptoms).
Mild Depressive Disorder: Suggested by the subthreshold PHQ-9 score.
Adjustment Disorder with Anxiety: Considered if a trigger were present, though less likely as the patient denies specific stressors.
Cardiac Event: Rule out based on lack of chest pain or palpitations.

Thyroid Stimulating Hormone (TSH): Necessary to check stability on levothyroxine, ideally with reflex to Free T3 and T4.
Complete Blood Count (CBC): To screen for anemia or infection contributing to fatigue.
Comprehensive Metabolic Panel (CMP): To assess kidney and liver function and electrolyte balance.
Electrocardiogram (EKG): Discussed but deemed unnecessary for this specific patient due to the absence of cardiac risk factors or clinical symptoms like palpitations or chest pain.
Pregnancy Test: Recommended for women of childbearing age before starting certain medications, depending on contraceptive use.
Gastrointestinal Assessment: Importance of assessing the "gut-brain axis" by asking about nausea, vomiting, or changes in bowel movements.

Cognitive Behavioral Therapy (CBT): The most research-backed counseling approach in conjunction with medication. A referral should be provided.
Sleep Hygiene: Essential due to reported insomnia; focus on regular schedules and environments.
Exercise: Recommend small, manageable goals (e.g., $5\text{ minutes}$ outside) to improve mood and reduce anxiety.
Lifestyle Modifications: Limit caffeine intake and reduce alcohol consumption.
Mindfulness: Practice deep breathing exercises and identifying triggers.
Safety Planning/Support Network: Identifying resources and people to contact during high-stress periods to ensure the patient does not feel alone.

Selective Serotonin Reuptake Inhibitors (SSRIs): First-line therapy.
- Sertraline (Zoloft): Start at a low dose of $25\,mg$ .
- Escitalopram (Lexapro): Recommended dose of $10\,mg$ , potentially starting at $5\,mg$ for the first week.
Side Effects to Monitor: Nausea, diarrhea, insomnia, and initial feelings of "dysregulation."
Treatment Timeline:
- Initial response takes $2\text{ to }4\text{ weeks}$ .
- Full therapeutic effect occurs at $4\text{ to }6\text{ weeks}$ (sometimes up to $8\text{ weeks}$ ).
Benzodiazepines (e.g., Xanax, Ativan): Not recommended for general anxiety disorder due to risk of dependence and difficulty with withdrawal. May be used very short-term (bridge therapy) but generally avoided as they are not first-line.
Alternatives for Crisis/Sleep: Hydroxyzine or Propranolol (the latter for physical symptoms like palpitations).

Constitutional: Patient is alert and cooperative.
Psychiatric: Patient appears mildly anxious. Mood is recorded as "anxious." Affect is congruent with mood.
Cardiovascular: Heart sounds S1 and S2 present with no murmurs, gallops, or rubs.
Respiratory: Lungs clear to auscultation bilaterally.

Follow-up Interval: Reassess in $4\text{ to }6\text{ weeks}$ to evaluate the effectiveness of medication and labs.
Prescription Dosing: Provide only a $30\text{-day supply}$ initially to ensure the patient returns for follow-up and to mitigate risks of overdose in patients with depressive symptoms.
Patient Education:
- Normalize anxiety as a treatable condition to reduce stigma.
- Stress the importance of adherence; do not stop medication abruptly to avoid rebound anxiety or neurological withdrawal symptoms.
- Tapering off may be considered after approximately $6\text{ months}$ of symptom stability.

Patient Red Red Flags: Questions were raised regarding suicidal ideation (SI), homicidal ideation (HI), and psychosis. These must always be assessed.
Diagnostic Redundancy: Discussion of avoiding repetitive questioning during Objective Structured Clinical Examinations (OSCEs) by separating the HPI and Review of Systems (ROS) effectively.
Clinical Hours Tracking: Mention of clinical hour reports via systems like Trellis and Exact.
SANE Training: Discussion regarding $40\text{ clinical hours}$ for Sexual Assault Nurse Examiner (SANE) training being used toward clinical requirements.
Preceptor Coordination: Clarification on designating a main preceptor in systems like Exact when working at sites with multiple providers (e.g., Healthtopia).