NGR6503 Clinical case study — anxiety (M.C.)

NGR6503 Clinical case study — anxiety (M.C.).

Clinical case study in generalized anxiety disorder, nursing assessment and evidence based treatment plan

Introduction
This case study profiles M.C., a 32 year old male who presents with persistent anxiety and functional decline. The goal is to give a concise clinical picture, justify a DSM-5-TR diagnosis, and present a nursing-led treatment plan grounded in recent evidence. You will find focused assessment data, a brief mental status exam, suicide risk appraisal, and a treatment plan with measurable goals. Use of screening tools and combined psychotherapy plus pharmacotherapy is emphasized. Global trends place anxiety disorders among the most common mental illnesses seen in primary and specialty care, with rising incidence among young adults after 2019 (Bie, 2024). This rise increases demand for scalable therapy options and for nurses to master screening and triage procedures. PMC

Identifying data and chief complaint
Patient initials, M.C. Age, 32 years. Sex, male. Occupation, logistics coordinator for a regional shipping firm. He lives with a partner and works full time but reports recent missed shifts and errors at work. Chief complaint, “I feel anxious all the time and I cannot stop worrying.” Family members report shorter temper and disturbed sleep. You should note reported sleep loss of five hours most nights for three months.

History of present illness
M.C. reports progressive worry about finances, performance at work, and health for nine months. Worry is daily and hard to control, with muscle tension, restlessness, impaired concentration, fatigue, and sleep fragmentation. He scores 14 on the GAD-7 screening tool, a score consistent with moderate severity (DeGeorge, 2022). Onset followed a period of increased workload and a minor motor vehicle crash without injury. He denies panic attacks or episodic derealization. He reports reduced social activity and avoidance of supervisors. Symptoms cause absenteeism and reduced productivity.

Psychiatric history and substance use history
No prior psychiatric admissions. He had brief counseling six years ago after a breakup. Past psychotropic use limited to a single SSRI trial which he stopped after two weeks because of nausea. He reports weekly alcohol use, two to three drinks on social evenings, with no blackouts or legal problems. He uses caffeine daily, four caffeinated beverages. He denies recreational drugs and tobacco use. Family history includes maternal anxiety disorder diagnosed in her 40s.

Personal and social history and review of systems
M.C. grew up in a two parent household and reports stable childhood attachments. He completed college. He is partnered and has no children. Work duties involve tight deadlines and irregular hours. He exercises sporadically and reports weight steady over six months. Review of systems is notable for intermittent palpitations, jaw clenching, occasional headaches, and sleep difficulty. No recent weight loss or syncope. No gastrointestinal bleeding or urinary symptoms.

Mental status examination
Appearance is neat. Grooming appropriate. Speech is normal in rate and volume. Mood reported as “anxious”, affect congruent and reactive. Thought process linear, goal directed, without delusions. No suicidal ideation at time of exam but passive hopelessness present. Insight is limited and judgment intact. Attention and memory intact on bedside testing.

Suicide and homicide assessment
M.C. denies active suicidal intent or plan. He states passive thoughts of worthlessness at times during low mood. He has no history of self harm. He denies homicidal ideation. Protective factors include stable partner, steady employment, and willingness to attend therapy. Safety plan developed with means restriction guidance and a 24 hour crisis line provided. Document follow up contact within 72 hours.

Medical history, allergies, current medications
Medical history includes seasonal allergic rhinitis and episodic tension headaches. He has no chronic cardiac or endocrine diagnoses. No known drug allergies. Current medications include occasional ibuprofen and an over the counter antihistamine. Immunizations up to date. Systems review earlier suggests somatic features consistent with anxiety rather than primary medical disease, but basic labs including thyroid function and CBC are ordered to exclude medical mimics.

Assessment and DSM-5-TR diagnosis
Clinical presentation meets DSM-5-TR criteria for generalized anxiety disorder, moderate severity, due to persistent excessive worry for more than six months with associated symptoms of restlessness, fatigue, impaired concentration, irritability, muscle tension, and sleep disturbance (American Psychiatric Association, 2022). Differential diagnoses include hyperthyroidism, stimulant use, and major depressive disorder with anxious features. Use of GAD-7 aids severity staging and progress monitoring (DeGeorge, 2022). For diagnostic clarity, order thyroid stimulating hormone, basic metabolic panel, and urine toxicology. American Psychiatric Association+1

Nursing theory, psychodynamic approach, treatment plan and goals
Use Peplau’s interpersonal relations theory as the nursing framework to structure engagement, boundary setting, and therapeutic communication. Nursing sessions will focus on anxiety symptom education, symptom monitoring, and graded exposure coaching. Short term goal one, reduce GAD-7 score to under 10 by eight weeks. Short term goal two, improve sleep to six to seven hours nightly within four weeks using sleep hygiene and brief sleep scheduling. Long term goal, restore full work attendance and decision making ability in three months. Psychodynamic elements include exploring core worry themes and attachment patterns which maintain worry cycles. Combine psychotherapy with pharmacotherapy where indicated to speed symptom reduction and preserve function (Zhang, 2022; Garakani et al., 2020). PMC+1

Specific interventions and medication plan
Begin therapist-guided cognitive behavior therapy referral, with option for internet-based CBT if scheduling limits access (Zhang, 2022). For pharmacologic treatment discuss SSRI options, for example sertraline or escitalopram, starting at a low dose and titrating as tolerated under psychiatric oversight (Garakani et al., 2020; DeGeorge, 2022). Avoid benzodiazepine initiation for long term use; reserve short courses for acute severe agitation while arranging definitive therapy (DeGeorge, 2022). Monitor for adverse effects, sexual side effects, and withdrawal risk. Coordinate care with primary care provider and psychiatry for medication initiation and follow up within two to four weeks after start. PMC+1

Nursing interventions, education and referrals
Your nursing role includes psychoeducation about anxiety physiology and normalizing symptoms while reducing stigma. Teach diaphragmatic breathing and brief progressive muscle relaxation in-session, then assign as daily practice. Provide written action plan and crisis contacts. Refer to licensed CBT therapist with experience in anxiety disorders and provide guided internet CBT resources if wait lists are long (Zhang, 2022). Screen periodically for substance escalation and depressive symptoms. Use the GAD-7 at baseline and at each follow up visit to track outcomes. PMC

Conclusions and clinical summary
M.C. presents with generalized anxiety disorder, moderate severity, with clear functional impact on work and sleep. Evidence supports therapist-led CBT as first line therapy with pharmacotherapy as an effective adjunct for symptom relief and improved function (Zhang, 2022; Garakani et al., 2020). Nursing interventions focused on assessment, safety planning, psychoeducation, and behavioral skill training will support recovery and reduce relapse risk (Chand, 2023). You should document progress using GAD-7 scores, symptom logs, and medication adherence notes. Arrange psychiatric follow up for medication management if symptoms do not improve by four to eight weeks. PMC+2PMC+2

References
American Psychiatric Association (2022) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Arlington, VA, American Psychiatric Association.

Bie F (2024) Rising global burden of anxiety disorders among adolescents and young adults, trends and risk factors 1990 to 2021. Lancet Public Health eClinicalMedicine. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11651023/ (Accessed 26 September 2025).

DeGeorge K C (2022) Generalized anxiety disorder and panic disorder in adults. American Family Physician 106(4): 249-258. Available at: https://www.aafp.org/pubs/afp/issues/2022/0800/generalized-anxiety-disorder-panic-disorder.html (Accessed 26 September 2025).

Garakani A, Murrough J W, Freire R C, Thom R P, Larkin K, Buono F D and Iosifescu D V (2020) Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in Psychiatry 11:595584. doi:10.3389/fpsyt.2020.595584. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786299/ (Accessed 26 September 2025).

Zhang W, Du Y and Yang X (2022) Comparative efficacy of face-to-face and internet-based cognitive behavior therapy for generalized anxiety disorder: a meta-analysis of randomized controlled trials. Frontiers in Psychiatry 13:832167. doi:10.3389/fpsyt.2022.832167. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9366007/ (Accessed 26 September 2025).

Chand S P (2023) Anxiety (Nursing). StatPearls. Available at: https://www.ncbi.nlm.nih.gov/books/NBK568761/ (Accessed 26 September 2025).

Use of APA 7th edition format and grammar

Identifying data, but only use the individual’s initials

Chief Complaint (CC)

History of Present Illness (HPI)

Psychiatric History and Substance Use History

Personal and Social History

Mental Status Examination

Suicide and Homicide Assessment

Medical History

Allergies

Current Medications

Review of Systems

History of Abuse, Neglect, and Trauma

Mental Status Examination

Assessment i.e. DSM 5-TR Diagnosis

Nursing Theory/Psychodynamic Approach

Treatment Plan and Goals

Education and Referrals

Conclusions and Summary

References page including evidenced-based data

Note: TurnItIn will be linked with this assignment
Topic: anxiety
(The medical case must be of a patient diagnosed with anxiety)