CC (chief complaint): Ms. Connie Weidre experiences fear and lack of air in her lungs when she leaves home.
HPI: Fear of the environment developed gradually after the death of the stress-causing mother. First the woman began to have a phobia and fear of flying on airplanes, and then of driving on the automobile highway. It later evolved into a fear of leaving the house, because the space outside the house is dangerous.
Past Psychiatric History:
- General Statement: A woman suffers from obsessive compulsive disorder
- Caregivers (if applicable): No applicable. She was raised by her mother, without a father.The mother suffered from x of generalized anxiety and was verbally abusive.
- Hospitalizations: There was no hospitalization.
- Medication trials: No applicable.
- Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric treatment.
Substance Current Use and History: The woman has no use for the substance, she only drinks a glass of red wine during dinner.
Family Psychiatric/Substance Use History: The psychological condition of the father is unknown. However, the mother, with hx generalized anxiety, was verbally abusive and abused benzodiazepines.
Psychosocial History: There is no family history of alcohol abuse, but mother abused medication. Ms. Connie Weidre has no history of alcohol or drug problems.
Medical History:
- Current Medications: The woman takes Tylenol and OTC Imodium.
- Allergies: Allergic to Zofran.
- Reproductive Hx: One daughter is 25 years old.
ROS:
- GENERAL: Sleep disorder.
- HEENT: headaches.
- SKIN:
- CARDIOVASCULAR:
- RESPIRATORY: Difficult breathing and gasping.
- GASTROINTESTINAL: Diarrhea.
- GENITOURINARY: Overactive bladder.
- NEUROLOGICAL:
- MUSCULOSKELETAL:
- HEMATOLOGIC:
- LYMPHATICS:
- ENDOCRINOLOGIC:
Objective:
- Physical exam: If applicable
- Diagnostic results: No applicable
Assessment:
- Mental Status Examination: The woman suffers from obsessive-compulsive disorder. The condition is characterized by the presence of recurrent, persistent, unwanted and intrusive thoughts, which patients feel an urgent need to perform in order to try to reduce or prevent the anxiety caused by the obsessions (Stein et al. 2019). For Ms. Connie Weidre began to develop the disease 15 years ago, she has constant obsessive thoughts that the environment will negatively affect her. Thus, she found protection from it in staying in her own home, in order not to suffer from floods or car accidents. Nevertheless, one of the symptoms of obsessive-compulsive disorder is a protective reaction to unwanted actions such as being outside the house, that is why the woman begins to gasp for breath (Robbins et al., 2019). Moreover, physical manifestations of the disease are weakness, sleep disturbance and headaches. All these signs are present in the medical history of Ms. Connie Weidre. Furthermore, diarrhea indicates that the person is constantly in a state of fear, which causes problems with the digestive system. Accordingly, it can be argued that Ms. Connie Weidre has not been treated for obsessive-compulsive disorder for 15 years.
- Differential Diagnoses: It is significant to remark that one of the most common personality disorders is anankastic disorder, in which insecurity and the need for control and orderliness are pronounced (Pull & Janca, 2021). Therefore, physicians may mistakenly diagnose this disorder to a woman. This is because the female has certain symptoms of the disorder, such as suffering from anxiety-phobic personality traits and experiencing difficulties in the emotional area of life (Stein et al. 2019). Additionally, often in the presence of anankastic personality disorder, a person is afflicted with obsessive thoughts (obsessions) and the compulsive behaviors that follow (compulsions). This may be an explanation for a woman’s phobia of the environment.
- Reflections: Thus, obsessive-compulsive disorder is a nervous disorder that can occur in a person and with proper treatment can be managed quickly. Meanwhile, with anankastic personality disorder, it is a character pathology that characterizes a person’s identity (Robbins et al., 2019). Accordingly, the woman’s problems are caused by the stress she experienced after the death of her mother, and the severe course of the illness is due to a lack of treatment. Accordingly, treatment of the disorder is quite possible, but it is more effective with a complex approach, that is, with a combination of pharmacotherapy and psychotherapeutic methods.
References
Pull, C. B., & Janca, A. (2021). Personality disorder (s) across diagnostic systems: What to assess and how. Current Opinion in Psychiatry, 34(1), 36-38. Web.
Robbins, T. W., Vaghi, M. M., & Banca, P. (2019). Obsessive-compulsive disorder: Puzzles and prospects. Neuron, 102(1), 27-47. Web.
Stein, D. J., Costa, D. L., Lochner, C., Miguel, E. C., Reddy, Y. C., Shavitt, R. G., & Simpson, H. B. (2019). Obsessive–compulsive disorder. Nature Reviews Disease Primers, 5(1), 1-21. Web.