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Asked by BarristerSnow794
Cleo is a preoperative transgender male aged 24. “My anxiety has taken over my life,” he says today. I can’t do anything without worrying or freaking out about the most insignificant details.” He goes on to say that persistent worry has always been a part of who he is. “I’m the family worrier.” He’s noticed himself becoming more anxious in social settings “regardless of who’s there” over the last year. I don’t know everyone, and I’m not sure if I’m being a good friend, guest, or host. If I don’t know the majority of the people, I’ll usually decline the invitation with some pathetic excuse.” He has frequent “freak out” moments throughout the day. Someone cuts me off on the highway; I pull over to the side of the road and freak out for 30 minutes. Someone cracks a crude joke in class; spend the rest of the day wondering if they were referring to me. It’s limitless!” He says he has constant tension in his back and neck, that he “crashes” at the end of the day from all the energy he expends worrying, and that “nothing shuts it off.”
Current medication from PCP: Testosterone Cypionate 20mg IM QWeek over the next month with plans to increase to 50mg and 100mg within the year as part of his transitioning. Ondansetron 8mg SL PRN Q12h for nausea associated with hormone therapy.Â
OTC Medications: Melatonin 3-5mg PO QHS PRN for sleep support with efficacy. Magnesium Supplement 600mg PO QD for sleep support with efficacy. Daily multivitamin with iron.
No significant acute or chronic illness is endorsed. No significant family history of mental illness. No significant family history of acute or chronic medical conditions. No history of previous psychiatric medication management. Engaged with a psychotherapist as part of his transitioning care plan.
What is the complete dynamic formulation and treatment plan, including diagnosis, specific medication and the dosing you would recommend. Describe what key topics and themes you would discuss with the patient as part of their informed consent to start or refuse the psychotropic medication you recommend.
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