Student Name College of Nursing-PMHNP,
Walden University
Faculty Name
Assignment Due Date
Subjective:
Chief complaint: “I have nightmares, always worried and difficulty concentrating in class”.
History of present illness: Dev is a 7 years old male suffered a case of mental health, where he
has been struggling with anxiety, obsessive-compulsive, and trauma and stressor-related
disorders. He complains of nightmares and is worried most of the time. He worries about his
mother and younger brother when at school. He reports being restless at school and keeps looks
out of the class window without proper concentration. No known allergy, patient was able to say
his name.
Past psychiatric history: Anxiety
Substance Current Use: Denied
Medical History:
• Current Medications: None
• Allergies: None
• Reproductive Hx: None
REVIEW OF SYSTEM
GENERAL: Dev is alert and oriented. Well dressed and focused throughout the interview.
HEENT: no discharge intact, moist
SKIN: warm and dry
CARDIOVASCULAR: no palpitations
RESPIRATORY: No cough, rales, or expiratory wheezing was noted neither was any
adventitious sounds heard.
GASTROINTESTINAL: No nausea, no vomiting, and no abdominal pain.
GENITOURINARY: Dev denies any burning upon urination and dribbling.
NEUROLOGICAL: Dev denies headaches, dizziness, and tingling in all her extremities.
MUSCULOSKELETAL: gait and steady
HEMATOLOGIC: No data available for this case
LYMPHATICS: not swollen
ENDOCRINOLOGIC: No data available for this case
Objective:
Assessment
Mental Status Examination: Dev is a young boy with an age-appropriate appearance; he is
dressed suitably and well groomed. He has a well-built body, and his body movements are well
coordinated. During the examination, he is cooperative, and his speech is normal in rate, tone,
and volume. His cognitive process is reasonable, and his memory is intact. His mood is down, he
cannot focus on one thing, and he is a little confused, but his perception and overall impression
are both fine.
Diagnostic Impression:
Anxiety disorder
The DSM-5 provides basic guidelines for clinicians to treat anxiety. The use of a common
collection of signs to identify patients allows them to recognize mental health problems more
effectively and in turn, create a more efficient treatment plan (APA, 2013). Anxiety persists for
at least 6 months more often than not and is clearly severe (Pogarell, Juckel, Norra, Leicht,
Karch & Schaaff N, et al. 2007).
Major depressive:
This criteria for diagnosing a depression is illustrated in the DSM-5. The patient must have 5 or
more symptoms within the same 2-week duration and either (1) depressed mood, or (2) lack of
pleasure or interest must be at least one of these symptoms (APA, 2013).
Nightmare Disorder DSM-5
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
the following criteria are used to diagnose nightmare disorder: The person experiences recurring
distressing dreams, which usually include threats to their safety or well-being that they try to
avoid and occur in the second half of the primary sleep cycle. Upon waking up from a
nightmare, the person is immediately alert and oriented. The nightmare causes severe anguish or
impairs crucial aspects of one's life (e.g., social or occupational). A substance’s physiological
effects (e.g., an abusive drug, a medication) do not cause the nightmares.
Differential Diagnosis:
1. Sad
2. Enuresis (nocturnal only)
3. Severe persistent nightmare disorder
4. Adjustment disorder with anxiety
Case Formulation and Treatment Plan
Case Formulation: Dave was tested for alcohol and substance use and tested negative.
Treatment Plan: Safety Plan, Client is not a threat to himself and others. The client will be
informed to seek medical attention and care if safety issues arise;
1. Treatment of anxiety and depression: Within 12 weeks of treatment, full symptom
remission with a 50% reduction in symptoms was achieved. Symptoms of depression will
be resolved, and function will be restored.
2. Intervention: administer Zoloft 25 mg daily Discussed the risks, benefits, major/common
side effects, and alternatives of the following medication plan with the patient, who stated
that he or she understood and agreed with the plan (Greiner et al 2019)
3. Individual Therapy 3 times weekly.
Reflections notes:
I would get the patient a physical test to see if there is something, wrong with him that is causing
their nightmares. I may refer the patient to a sleep specialist if their recurring dreams reveal
underlying anxiety.
If the patients sleep is being disrupted, I may suggest an overnight sleep study to see if the
nightmares are linked to another sleep condition. While the patient sleep, sensors on his body
will record and monitor his brain waves, blood oxygen levels, heart rate and respiration, as well
as eye and leg movements. It's possible that he'll be videotaped while sleeping to document your
habits.
Legal/ethical considerations
Fears of symptom worsening, high treatment dropout rates, client safety concerns, and the
blurring of therapist-client boundaries are all ethical problems with exposure treatment for
anxiety. Although considerations have been made about exposure treatment in general, given the
fragile character of the population, specific issues have been raised about the treatment of post-
traumatic stress disorder (PTSD). Despite these reservations, data overwhelmingly supports
exposure therapy's efficacy and safety (Altis, Elwood & Olatunji, 2015).
References
Altis, K. L., Elwood, L. S., & Olatunji, B. O. (2015). Ethical issues and ethical therapy
associated with anxiety disorders.ICurrent topics in behavioral neurosciences,I19, 265–278.
https://doi.org/10.1007/7854_2014_340
Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder.ILancet (London,
England),I387(10027), 1561–1572. https://doi.org/10.1016/S0140-6736(15)00241-X
Paris, J. (2018). Clinical features of borderline personality disorder. In W. J. Livesley & R.
Larstone (Eds.),IHandbook of personality disorders: Theory, research, and treatmentI(pp. 419–
425). The Guilford Press.
