Mental Health Case Study
Madeline May, age 38, has an appointment today at 10:00 AM in a primary care clinic with
John Dennis, NP. John enters the exam room and introduces himself. Without making eye
contact with John, Madeline tells John she needs to know if she is going crazy.
1. What assessment questions should John ask?
Can you describe the way that you are feeling?
Do you have any thoughts of wanting to harm yourself or others?
How long have you felt this way? How often do these feelings
occur? Has anything helped or worsened the symptoms?
How much caffeine do you consume? (Munir & Takov,
2022) What medications do you take?
Do you have any allergies?
Do you smoke, use illicit drugs or drink alcohol? (Munir & Takov,
2022) Can you tell me about your living situation? Do you feel safe?
How is your family dynamic?
Tell me about your occupation. (Munir & Takov, 2022)
How have your recent symptoms affected your daily
life? Do you have any health issues? Mental health
issues? Any family history of mental health issues?
Have you ever experienced any traumatic events? (NIH, 2022)
Have you experienced any of the following symptoms- tiredness, fatigue,
sleep disturbance, weight change, hair loss, changes in bowel habits, restlessness,
muscle tension, difficulty concentrating, irritability (Munir & Takov, 2022).
Madeline is a real-estate agent and married with children. She reports that she worries
about maintaining her status as the top realtor in her company, about being a good
mother, and about getting older. In fact, she reports worrying about everything. She
says she feels high strung, is easily irritated, and has difficulty concentrating. She feels
muscle tension all over her body. As she talks she fidgets, shakes her leg constantly,
makes no eye contact, and clears her voice frequently. “I realize my fears are
unjustified, but I can’t seem to control them”. After reviewing Madeline’s medical
records John identifies the diagnosis of Generalized Anxiety Disorder (GAD).
2. What objective and subjective data indicate Madeline is having GAD?
Objective- fidgeting, restless leg, no eye contact, clears voice frequently
Subjective- worries about “everything” including job, family and the future, feels high
strung, irritable, difficulty concentrating, muscle tension, knows fears are unjustified
but cannot control them
3. What interventions could John suggest to deal with Madeline’s anxiety?
John could refer Madeline to a therapist to start psychotherapy. John could also prescribe a
SSRI, SNRI or buspirone. John can also refer Madeline to a support group and educate her
on healthy habits to reduce anxiety such as eating healthy, getting regular exercise, getting
enough sleep, meditation, and reducing caffeine intake (NIH, 2022).
Madeline May, age 38, has an appointment today at 10:00 AM in a primary care clinic with
John Dennis, NP. John enters the exam room and introduces himself. Without making eye
contact with John, Madeline tells John she needs to know if she is going crazy.
1. What assessment questions should John ask?
Can you describe the way that you are feeling?
Do you have any thoughts of wanting to harm yourself or others?
How long have you felt this way? How often do these feelings
occur? Has anything helped or worsened the symptoms?
How much caffeine do you consume? (Munir & Takov,
2022) What medications do you take?
Do you have any allergies?
Do you smoke, use illicit drugs or drink alcohol? (Munir & Takov,
2022) Can you tell me about your living situation? Do you feel safe?
How is your family dynamic?
Tell me about your occupation. (Munir & Takov, 2022)
How have your recent symptoms affected your daily
life? Do you have any health issues? Mental health
issues? Any family history of mental health issues?
Have you ever experienced any traumatic events? (NIH, 2022)
Have you experienced any of the following symptoms- tiredness, fatigue,
sleep disturbance, weight change, hair loss, changes in bowel habits, restlessness,
muscle tension, difficulty concentrating, irritability (Munir & Takov, 2022).
Madeline is a real-estate agent and married with children. She reports that she worries
about maintaining her status as the top realtor in her company, about being a good
mother, and about getting older. In fact, she reports worrying about everything. She
says she feels high strung, is easily irritated, and has difficulty concentrating. She feels
muscle tension all over her body. As she talks she fidgets, shakes her leg constantly,
makes no eye contact, and clears her voice frequently. “I realize my fears are
unjustified, but I can’t seem to control them”. After reviewing Madeline’s medical
records John identifies the diagnosis of Generalized Anxiety Disorder (GAD).
2. What objective and subjective data indicate Madeline is having GAD?
Objective- fidgeting, restless leg, no eye contact, clears voice frequently
Subjective- worries about “everything” including job, family and the future, feels high
strung, irritable, difficulty concentrating, muscle tension, knows fears are unjustified
but cannot control them
3. What interventions could John suggest to deal with Madeline’s anxiety?
John could refer Madeline to a therapist to start psychotherapy. John could also prescribe a
SSRI, SNRI or buspirone. John can also refer Madeline to a support group and educate her
on healthy habits to reduce anxiety such as eating healthy, getting regular exercise, getting
enough sleep, meditation, and reducing caffeine intake (NIH, 2022).
