Case history -Case 1
CASE 1
A 28 year-old female presents to the clinic with complaints of joint pain (arthralgia)
and intermittent low back pain. Patient cannot recall any mechanism of injury. She
reports she has trouble falling asleep at night and is unable to get a good night’s rest.
She often feels "restless" or "on edge", which she associates with not sleeping. She
states she constantly worries about her performance in school, her family, and her
mother’s health, who has recently been diagnosed with Stage IV Small Cell
Carcinoma. Patient also states she wakes up at night with throbbing headaches that
last for a couple hours. She feels tense the majority of the day, causing her to feel
stiff. She also has difficulty paying attention in class and finishing her homework.
Subjective:
Joint pain, low back pain, headache, muscle stiffness, difficulty sleeping and paying
attention for approximately a year. Previously diagnosed with PTSD and treated with
CBT.
Demographic Information: Second Year Graduate Student, female, 28
Medical diagnosis if applicable: Diagnosed with PTSD in February of 2000.
Co-morbidities:
Hypertension, drinks 10+ alcoholic beverages per week (possible substance abuse),
Depression
Previous care or treatment: PTSD treated with Cognitive Behavioral Therapy by
Clinical Psychologist following car crash in 2000.
Clinical Impression:
¬ Hypertension
¬ Tachycardia
¬ Increased respiratory rate
¬ Red Flags:
Patient used phrases such as “restless and on edge” to describe her current state.
Patient has a significant medical history and suffered from PTSD and possible
substance abuse, along with the stress of school and her mother’s health.
¬ Outcome Measures: Patient scored significantly high on the GAD-7, Penn State
Worry Questionnaire & +McGill Pain Questionnaire.
INTERVENTION
The scores from the outcomes measures revealed that the patient has signs and
symptoms that are consistent with a moderately severe form of GAD. Therapist
recommended that the patient follows up with her primary care physician to discuss
the results of the outcome measures and see what approaches her physician
recommends would be best for her since she has a significant medical history.
The therapist explained to the patient that physical therapy can not cure her possible
GAD; however therapists can treat the symptoms through education because there is
no specific physical therapy intervention to treat GAD.
Therapist provided educational information pertaining to anxiety management that
the patient can utilize outside of therapy. Stress management techniques such as:
mediation, deep breathing, progressive muscle relaxation techniques, exercise and
modifying her diet. Therapist discussed patient’s alcohol consumption and education
on alcoholism and the effects it has on the mind and the body.
Name -
Age -28
Sex- Female
Education- Second Year Graduate Student
Occupation-Student
Socio economic status
Complaints and their duration-
Complaints of joint pain (arthralgia) and intermittent low back pain. Finding trouble
in sleeping due to which she feels restless and while sleeping she often faces
throbbing headaches that last for a couple of hours at night. She constantly worries
and takes tension about her performances throughout the day which makes her feel
stiff. She faces concentration problems while completing her work.
HISTORY OF PRESENT ILLNESS
Onset is acute with a continuous duration of illness with gradual deterioration in
progress.
Precipitating factors: Joint pain, low back pain, headache, muscle stiffness, difficulty
sleeping and paying attention for approximately a year.
Associated disturbances: Disturbance in concentration and not able to deliver
homework of the college.Constant tension and worry about her performance is
affecting her sleep.She feels stiff while thinking about her work.
Negative History-
Suffered from PTSD and possible substance abuse, along with the stress of school and
her mother’s health. The patient has signs and symptoms that are consistent with a
moderately severe form of GAD.
PAST PSYCHIATRIC AND MEDICAL ILLNESS
Patient has a significant medical history and suffered from PTSD and possible
substance abuse, along with the stress of school and her mother’s health.
The patient has signs and symptoms that are consistent with a moderately severe
form of GAD.
FAMILY HISTORY-
Her mother’s health, has been diagnosed with Stage IV Small Cell Carcinoma.
PERSONAL HISTORY
Hypertension,Tachycardia, Increased respiratory rate Joint pain, low back pain,
headache, muscle stiffness, difficulty sleeping and paying attention for approximately
a year. Previously diagnosed with PTSD and treated with CBT.
MENTAL STATUS EXAMINATION
GAD-7
Post-Traumatic Stress Disorder 66% 81% 3.5
Penn State Worry Questionnaire
McGill Pain Questionnaire.
SUMMARY
The patient has shown signs of Hypertension, Tachycardia,Increased respiratory rate,
Joint pain, low back pain, headache, muscle stiffness, difficulty in sleeping. Patient
has a significant medical history and suffered from PTSD and possible substance
abuse, along with the stress of school and her mother’s health. She had moderately
severe of GAD. The patient should follow up with her primary care physician to get
best treatment. The physical therapy can not cure her possible GAD because its
moderately severe and medications can help to get it cured much faster; however
therapists can treat the symptoms through education because there is no specific
physical therapy intervention to treat GAD.
