Description
Include the Following Sections:
Management Plan: Write a final management plan for the client you presented in the Week 2 Mental Health Case Study Discussion (I ATTACHED THE DOCUMENT WITH THE CASE STUDY BELOW). Include the following components in the management plan:
Primary diagnosis
Recommended diagnostic testing based on clinical practice guidelines
Medications
Nonpharmacologic interventions
Recommended follow-up schedule and referrals with rationale
Analysis: Complete an analysis of the case and management plan:
Pathophysiology: Write a summary of the underlying pathophysiology of the diagnosis.
Pharmacology: Write a summary of how the pharmacological agent chosen acts to reverse or control disease pathology.
Additional analysis: Describe how clinical practice guidelines were used to make a diagnosis and management plan. If the case is based on a client you have seen in practicum, discuss how the client’s care compared to the recommended treatment guidelines.
Follow-up and referrals: Describe what actions should be taken at the time of follow-up. If applicable, describe the client’s symptoms and response to the plan of care at the follow-up visit.
Quality: Discuss any information you learned in the weekly discussion that impacted your approach to the creation of the client’s management plan or would inform your care of a future client with a similar disorder.
Coding and billing: Identify all appropriate ICD-10 codes for the client.
Evidence-Based Resources
Support the management plan and analysis with evidence from appropriate sources published within the last five years and the most recent clinical practice guidelines.
Select articles and guidelines that represent a logical link to the management plan.
Provide in-text citations and complete APA references for all selected scholarly resources.
Unformatted Attachment Preview
Patient Case Study: Obsessive-compulsive disorder
Thesis statement: The patient, a 34-year-old male, presents with complaints of persistent and
intrusive thoughts that he cannot control, leading to excessive repetitive behaviors that
significantly interfere with his daily life.
I. INTRODUCTION
A. Brief overview of obsessive-compulsive disorder (OCD)
B. Significance of studying OCD in clinical psychology
C. Purpose of the case study
II. PATIENT BACKGROUND AND PRESENTING SYMPTOMS
A. Description of the patient’s demographic information
B. Comprehensive subjective data regarding the patient’s complaints and history of present
illness
C. Identification of risk factors and family history of anxiety disorders and OCD
III. OBJECTIVE FINDINGS
A. Physical examination findings
1. Muscle tension and its implications
2. Fatigue and its impact on the patient’s well-being
3. Headaches and their potential causes
4. Gastrointestinal discomfort and its connection to stress and anxiety
B. Mental status examination
1. Anxiety and restlessness as a result of obsessions and compulsions
2. Avoidance behaviors and their impact on the patient’s daily functioning
3. Cooperative attitude and insight into the condition
4. Difficulty controlling compulsions and its distressing nature
IV. DIAGNOSTIC ASSESSMENT
A. Psychological Evaluation
B. Screening for Co-occurring Disorders
C. Laboratory Tests
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Patient Case Study: Obsessive-compulsive disorder
Name
Department: University
Professor
Course Code: Course Unit
Date
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Patient Case Study: Obsessive-compulsive disorder
Subjective Data
Chief Complaint: The patient, a 34-year-old male, presents with complaints of
persistent and intrusive thoughts that he cannot control, leading to excessive repetitive
behaviors that significantly interfere with his daily life.
History of Present Illness: The patient reports a history of recurring thoughts about
contamination and a strong need to engage in cleaning rituals. These obsessions and
compulsions have gradually intensified over the past two years, impacting his ability to
maintain employment and interpersonal relationships. The patient describes feeling distressed
and anxious due to his inability to control these thoughts and behaviors.
Demographic Data: The patient is a 34-year-old male, married, and working as a
project manager in a local corporation. He resides in a suburban neighborhood with his wife
and two children.
Risk Factors: No significant risk factors were identified during the initial assessment.
A family history of anxiety disorders and OCD is reported.
Previous Medical, Surgical, and Psychiatric History: No significant medical or
surgical history is reported. The patient has no history of psychiatric illnesses.
Objective Data:
Physical Exam Findings:
During the physical examination, the patient presented with signs indicative of the
impact of obsessive-compulsive disorder (OCD) on his physical well-being. Firstly, the patient
displayed visible muscle tension, particularly in the upper trapezius and cervical muscles, as
evidenced by the tautness and tenderness upon palpation (Arshad & Bacha, 2022). This finding
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suggests the presence of heightened stress and anxiety, commonly associated with the
persistent intrusive thoughts and compulsive behaviors characteristic of OCD. Additionally,
the patient exhibited signs of fatigue, characterized by a general lack of energy and a subdued
affect, which is likely a result of the psychological and emotional strain associated with
managing his symptoms. Furthermore, the patient reported occasional headaches, which may
be attributed to the increased muscle tension and the psychological distress experienced as a
consequence of the disorder. Lastly, the patient mentioned intermittent gastrointestinal
discomfort, such as mild nausea and decreased appetite, potentially resulting from the
heightened levels of stress and anxiety associated with the condition.
Mental Status Exam:
Anxiety and Restlessness: The patient’s evident anxiety and restlessness are indicative
of the emotional distress they experience due to their obsessions and compulsions. These
symptoms are common in individuals with OCD and often result from the constant intrusive
thoughts that generate significant anxiety (Mishra et al., 2023). The patient’s restlessness may
be a coping mechanism to deal with the discomfort associated with their obsessions,
highlighting the profound impact OCD has on their daily life.
Avoidance Behaviors: The patient’s engagement in avoidance behaviors, such as
excessive hand-washing and avoidance of perceived contaminated objects, is a hallmark of
OCD. These behaviors are an attempt to reduce the anxiety triggered by obsessions but
paradoxically reinforce the obsessions, creating a vicious cycle. The patient’s avoidance
behaviors significantly disrupt their daily functioning and illustrate the impairment caused by
the disorder.
Cooperative and Insightful: The patient’s cooperative attitude and insight into their
thoughts’ irrationality are positive signs. The patient’s willingness to participate in the
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examination indicates their openness to receiving help, which is crucial in the treatment of
OCD. Furthermore, their awareness of the irrational nature of their obsessions suggests that
they have some degree of insight into their condition, which can be harnessed in therapy.
Difficulty Controlling Compulsions: The patient’s reported difficulty in controlling
their compulsions is a common feature of OCD. According to Kim et al. (2023), this highlights
the distressing nature of the condition, where individuals often recognize the irrationality of
their behaviors but find it highly challenging to resist the urge to perform them.
Recommended Diagnostic Tests:
1. Psychological Evaluation: Conduct a comprehensive psychological assessment to
evaluate the severity of the obsessions and compulsions and their impact on the patient’s
daily life.
2. Screening for Co-occurring Disorders: Assess the patient for any comorbid conditions,
such as depression or anxiety, to provide a comprehensive treatment plan.
3. Laboratory Tests: Perform routine blood tests to rule out any underlying medical
conditions that may contribute to the patient’s symptoms.
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References
Arshad, A., & Bacha, U. (2022). The Control Center of Anger. In The Psychology of
Anger (pp. 51-77). Cham: Springer International Publishing.
https://doi.org/10.1007/978-3-031-16605-1_3
Kim, S. T., Seo, J. H., Park, C. I., Kim, H. W., Boo, Y. J., Kim, H., … & Kim, S. J. (2023).
Core clinical symptoms and suicidal ideation in patients with obsessive–compulsive
disorder: A network analysis. Psychiatry and Clinical Neurosciences, 77(2), 110-117.
https://doi.org/10.1111/pcn.13503
Mishra, A. K., Varma, A. R., & Varma, A. (2023). A Comprehensive Review of the
Generalized Anxiety Disorder. Cureus, 15(9).
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