The primary diagnosis is Generalized anxiety disorder (GAD)
As per DSM-5 or Diagnostic and Statistical Manual of Mental Disorders, 5th ed, diagnostic criteria for GAD: The patient with excessive worry and anxiety for six months, with at least three of the following symptoms as fatigue, restlessness, muscle tension, irritability, difficulty to concentrate and sleep disturbance, which is seriously affecting the functioning of the patient. Moreover, which are not related to any medical condition or a physiological effect of substance or drug abuse.
GAD-7 is a validated screening tool for diagnosing GAD, and the score ranges from 0 to 21 with cut-off points of 5, 10, and 15, representing mild, moderate, and severe anxiety, respectively.
In this case study, the patient’s GAD-7 score of 12 indicates that the patient has moderate anxiety.
The first-line medication for GAD is SSRIs or selective serotonin reuptake inhibitors, SNRIs, or serotonin-norepinephrine reuptake inhibitors. TCA or tricyclic antidepressants also treat GAD, but they should be used with caution due to the adverse effect of the medication.
Therefore, I will start
Rx # Escitalopram 10 mg tablet
Sig # Take one tablet by mouth daily
Dispense # 30
Refill # 1
The dose may increase after one week, and the maximum dosage is 20 mg/day, then taper the dose gradually to D/C.
The medications should titrate slowly, and due to the typical delay in the onset of action, it should not be considered ineffective until the treatment is four weeks and titrated to its maximum dose. Moreover, the medication should use for 12 months after improved symptoms, and some may require prolonged treatment.
In association with pharmacotherapy, Psychotherapies such as CBT (cognitive behavioral therapy) or CT (Cognitive therapy) are also considered the first-line treatment for GAD. CBT uses various strategies such as psychoeducation, worry exposure, relaxation, applied relaxation, problem-solving, cognitive restructuring, and interpersonal psychotherapy, whereas CT teaches patients to evaluate their anxious thoughts objectively. In some cases, combining psychotherapy and pharmacotherapy is very effective in treating GAD.
Psychotherapy should be performed weekly for at least eight weeks to assess its effect.
At first, establishing a trusting relationship between the patient and the provider is a significant step in treating GAD, which helps to eliminate the patient’s fear and enhance the treatment progress.
The patient should also educate about the side-effect of the medications, such as suicidal ideation and symptoms of serotonin syndrome. These scenarios need immediate medical attention; therefore, the patient should report it to the doctor immediately.
Educate the patient about the importance of adequate physical activity (Exercise for at least 150 minutes each week), sleep hygiene, and avoiding potential triggers such as stimulants, caffeine, stress, nicotine, Etc.
Smoking cessation teaching is an integral part of education; in this case, the patient is a non-smoker.
Instruct the patient to choose a tension-reduction technique that fits her lifestyle and personality. Therapists offer training and counseling in these techniques. Some insurance plans may cover the training to help with anxiety.
Besides, Relationships have a significant role in reducing anxiety. Therefore, I will inform the patient to try to spend more time with trusted family members and friends.
Also, eating a healthy diet of fruits, whole grains, low-fat dairy products, and vegetables may help to reduce the symptoms. And avoid eating food high in fats, added sugars, or salt.
There is no specific lab test to diagnose GAD. Although, I will order for TSH or thyroid panel to evaluate any thyroid disorder that contributes to her symptoms. In addition, I will also order CBC and BMP to get the baseline.
Follow up in two weeks to evaluate medication effect. However, the medication may take four weeks to see the desired effect, so we can decide on medication titration based on the patient’s evaluation.
I will refer the patient to a psychiatrist for further evaluation and treatment.
Pathophysiology and Pharmacology:
GAD occurs mainly by a chemical imbalance, environmental factors, or hereditary. In this case study, the patient’s long-lasting stress developed after the divorce changed her chemical balance that controls her mood or mental stability. Serotonergic, noradrenergic, and other neurotransmitters play a significant role in the body’s response to stress. In most cases, low serotonin levels and elevated noradrenergic systems are the common causes of the development of GAD in patients. Therefore, SSRIs and SNRIs are the primary pharmacological treatment for GAD.
2. Additional analysis of the case:
DSM-5 or Diagnostic and Statistical Manual of Mental Disorders, 5th ed, diagnostic criteria for GAD recommended by the American Psychiatric Association provides the guidelines for diagnosing and treating Generalized anxiety disorder (GAD).
As I ordered, a two-week follow-up helps evaluate medication adherence and effectiveness and determines the need for titration of the medication. Due to the delayed onset of action, these medications need four weeks to reach their desired effect. If the medication is still not effective after four weeks with the max dose, warrant the need to change the medication and referral to the psychiatrist for the close monitoring of the patient.
A comprehensive history collection is the primary diagnosing tool for psychiatric illness. Therefore, creating a trusted relationship with the patient is the critical step that will promote in-depth history collection and helps to diagnose the condition precisely.
5. Coding and Billing. Any or all CPT and ICD-10 codes that should have been used
ICD-10 code for Generalized anxiety disorder (GAD) – F41.1
CPT code- 99213
(List them and name them only.