Soap Note 1
Abstract
The cause of anxiety disorder on a person is not known fully. The hypothesis is that neurotransmitters, which include dopamine, serotonin, and norepinephrine levels, change. The male patient complained of having many symptoms that can be misinterpreted for musculoskeletal insufficiencies. Since it is caused by the neurotransmitter, which is in the brain, making physical therapy cannot cure anxiety directly. The physical therapist assists those who undergo ANXIETY DISORDER to be mindful of their anxiety. This case study aims to show how ANXIETY DISORDER cannot be cured using physical therapy, but it can help decrease physical signs and symptoms related to ANXIETY DISORDER.
Introduction
Subjective
Anxiety disorder affects the population in the U.S, about 3.1%. ANXIETY DISORDER is associated with excessive and constant worrying for more than six months. ANXIETY DISORDER can be seen as a primary or secondary disorder, dependent on the start of the disease. When at a younger age, it is in the primary and secondary later in life. ANXIETY DISORDER also has other disorders that have depression and anxiety that can lead to a pre-existing situation, which is the worst, which includes; musculoskeletal, cardiopulmonary, neurological, and Gastrointestinal system. This disorder can show in different ways, comprising physical, cognitive, and behavioral characteristics.
A 58 years old male patient presents to the clinic with signs and symptoms of joint pain and discontinuous pain on the lower back. He claims that he did not injure himself. The report is that he finds it hard to fall asleep, and when he sleeps, it is not enough to rest—making him feel restless, which is related to the lack of sleep. He worries about his family since he is a married man and his job of being a salesperson of the chances of losing his job due to the closing of borders hence, minimizing goods to the company he is working in. Past psychiatric medication is that he was diagnosed with stage IV small cell carcinoma. He argues that he wakes up with an aching headache that lasts for some hours; during the day, he feels tense, making him stiff a lot. In his job, he has found it hard to sell because of not paying attention. The height of the man is 5.7ft, and his weight 197 pounds after taking the test. Signs and symptoms low back pain, joint pain, muscles, headache, stiffness, sleeping difficulty, and paying attention for almost a year. He was previously diagnosed with PTSD and was healed with CBT. The history of PSTD was in February of 2008.
Observation
Vitals: BP: 146/92mmHg of hypertension, HR: 98 bpm, RR= bpm. There is muscle tightening in palpable in the forward flexed head, upper trapezius with kyphosis, which is increased. The patient hand was cold and sweated profusely and clammy to touch.
- Shoulder AROM = decrease of bilateral shoulder flexion.
- Myotomes weakness= c1 to c3 and c3/c4
- Weakness myotomes= L4/L5,L5/S1
- LE AROM- inadequate trunk, with flexion in knee and deficit ankle dorsiflexion
The metal exam showed that the patient constantly used terms such as edge and restlessness to describe the current condition. The patient had a medical history and affected with PSTD in the past, along with the family stress and job stress. Test from screening revealed he had a high score on anxiety disorder-7, McGill pain Questionnaire, and Penn State worry questionnaire.
Assessment
The medical assessment score revealed that the patient was suffering from anxiety disorder due to signs and symptoms. The therapist advised him to follow up with the primary physician to analyze the result and give him the recommendation to help her considering her past medical history. The therapist told him that using physical therapy will not help to cure; but with education. Therapy gave him some educational information related to fighting anxiety disorder together with physical therapy. Some of the education include deep breathing, meditation, exercise, and muscle relaxation method and diet modification. Therapy also warned about the use of alcohol the effect that it has on the body and mind.
Plan
After being identified with the physician’s anxiety disorder, he was told to go back to PT to help in the treatment of deficit musculoskeletal, which is secondary to anxiety disorder. The physician prescribed Paxil, which will help in the increase of serotonin; this motivated him to go for therapy. After three weeks, his AROM enhanced, and the anxiety disorder after being measured reduced greatly.
Anxiety disorder= 9/21
Questionnaire of McGill Pain= 31/78
Questionnaire Penn state worry= 47/80
In the second session technique of Beck Depression was implemented inventory, which he scored 32/63 to get the depression level. This technique was used since it is a reliable and quick indicator of depression of a person. The questionnaire was used to help know the stress, and the anger score was 67/80, which was higher than normal. He claimed that when talking, he felt better since he was free talking to a stranger. With the activity completion, he was able to identify himself on how his colleagues viewed him. Psychotherapy, when dealing with disorder anxiety, is the best take; it has a long-lasting positive effect. Plan cares include; psychotherapy, interpersonal therapy medication, and cognitive behavior therapy. The lab needed to be was a cognitive behavior therapy session, and the availability of medication was given to him. The alternative is the use of antidepressant medication since, after taking it, he claimed to be feeling better and having enough sleep. The referrals of him feeling better were indicated in the beck depression inventory, which improved a lot. In my opinion, the patient should return when he is feeling unwell since he his having enough sleep that shows him his well. Yes, he was appropriate for the nurse practitioner since, when he felt better, he did not go back and continue with therapy. The nurse will help to follow up. No, it did not require another health care provider.
Education
He never returned when he felt better; hence, education is important to him to show how therapy using CBT will help him in the future. Community resources would be the use of nurse practitioners who will always check on him through phone calls and go and talk to him, and that will keep the door open for him when he needs therapy in the future.