Ms. Peggy Isaac was referred by her primary care physician. Her primary care physicians complaint is that she is always on the edge, uncharacteristically tense and fatigued. CLINICAL NOTATIONS:
Ms. Isaac is a 41 year old single female. She does not have any children, employed as an administrative assistant. She was referred by her primary care physician. Ms. Isaac previously lived with her long-time boyfriend until eight months earlier, at which time he had abruptly ended the relationship to date a younger woman. Her behavior changed she started agonize about routine tasks, possibility of making mistakes at work and difficulty focusing. Patient denies any history of mental health treatment. Three months prior to the evaluation, Ms. Isaac began to avoid going out at night, fearing that something bad would happen and she would be unable to summon help. More recently, she does not go out in the daytime and her fear is something is going to happen to her. She does not like being alone, having had boyfriends constantly since age 16. Prior to her recent breakup she had a routine of working, jogged daily and maintained a solid network of friends. Ms. Isaac admitted to feeling sad for several weeks and denies being suicidal. No concerns with her weight and her sleep is fine. She did describe significant anxiety, with a Beck Anxiety Inventory score of 28, indicating severe anxiety.
DIAGNOSIS:…show more content… Her diagnosis is Generalized Anxiety Disorder- 300.02
Long-term goal(s):
Peggy’s long term goal is to reduce her frequency and intensity of anxiety to return to her daily functioning is not impaired.
Objectives
Identify situations and thoughts that cause me to have problems with my anxiety.
Return to previous daily activities.
Educate patient on gaining an understanding of her anxiety. _____________________
