Brain is a 25-year-old preoperative transgender male.

Brain is a 25-year-old preoperative transgender male. He presents today with a chief complaint of “My anxiety has taken over my life. I can’t do anything without constantly worrying or freaking out about the most mundane things.” He goes on to describe how persistent worry has always been “part of who I am. I’m the worrier in the family.” In the past year, he’s noticed himself becoming more anxious in social settings “regardless of who’s there. I could know everyone and I worry whether I’m being a good friend, guest, or host. If I don’t know most of the people, I’ll usually decline the invite with some lame excuse.” He has frequent moments through the day “where I freak out. Someone cuts me off on the road – pull to the side and freak out for 30 minutes. Someone make a crude joke in class – ruminate over whether they were talking about me for the rest of the day. It’s endless!” He feels constant tension in his back and neck, endorses feeling like he “crashes” at the end of the day from all the energy he puts into worrying, and “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. 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. Brian has Generalized anxiety disorder. Assessing Luke in accordance with APA guidelines 10-14 for transgender and gender nonconforming people. Discuss and outline what additional questions or concerns you would want to ask after understanding the guidelines. How might this inform your treatment recommendations? What bias do you notice in yourself? How do you address your own thoughts and opinions in working with Robert?

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