Case Report Template 2017

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Introduction

Generalized Anxiety Disorder affects 3.1% of the U.S population. GAD is characterized by constant and excessive worrying, for at least six months or more. GAD can be considered a primary or secondary disorder, depending on the time of onset. Diagnosis at a young age is considered a primary disorder, and secondary is normally diagnosed later in life and is associated with other disorders. GAD is most often associated with other disorders that involve anxiety and depression and can lead to or worsen pre-exisiting conditions. Many of the bodies systems can be affected by GAD, including: Cardiopulmary, Musculoskeletal, Gastrointestinal and Neurological systems. This disorder can manifest in several ways, incorporating physical, behavioral, and cognitive characteristics.

Case Presentation

A 28 year-old caucasian 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 nights 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 mothers 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+ alcholic 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.
• Self Report Outcome Measures: GAD-7 = 16/21, Penn State Worry Questionnaire (PSWQ) = 64/80, McGill Pain Questionairre = 42/78
• Physical Performance Measures: Oswestry Disablity Index (ODI) = 38%
• Objective : Vitals: HR= 98 bpm (tachycardia), BP: 146/92 mmHg (hypertension), RR= 24 bpm. Palpable muscle tightness in upper trapezius, forward flexed head along with increased kyphosis. Patient appears to be perfusely sweating and hands are cold and clamy to touch.
• Cervical AROM= limited extension and bilateral rotation
• Shoudler AROM= bilateral shoulder elevation decreased as well as shoulder flexion. All other shoulder AROM WFL.
• Myotomes= C1/C2, C2/C3 and C3/C4 weakness
• UE sensation intact
  
• LE AROM= limited trunk flexion/extension, along with knee flexion and ankle dorsiflexion deficits.
• Myotomes= L4/L5, L5/S1 weakness
• LE sensation intact

Clinical Impression

Summarization of examination findings, working diagnosis and targeted interventions

Intervention

• Phases of Interventions (e.g. protective phase, mobility phase, etc.)
• Dosage and Parameters
• Rationale for Progression
• Co-interventions if applicable (e.g. injection therapy, medications)

Outcomes

Findings Over time

Discussion

Summary Statement which should include related findings in the literature, potential impact on clinical practices

Acknowledgements

If someone provided assistance with the preparation of the case study, we thank them briefly. It is neither necessary nor conventional to thank the patient (although we appreciate what they have taught us). It would generally be regarded as excessive and inappropriate to thank others, such as teachers or colleagues who did not directly participate in preparation of the paper.

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