History:
- Date of last visit and last management plan from prior visit: 15 October 2024, patient was stable on current medication regimen (Fluoxetine 20mg daily).
- Symptoms present at last visit: Mild anxiety, occasional low mood, improved from initial presentation.
- Patient age: 34 years old.
- Whether the patient was accompanied and by whom: Patient attended alone.
- Current issues, reasons for visit, and history of presenting complaints: Patient reports a recent increase in anxiety symptoms, particularly social anxiety related to a new job role. Experiences difficulty concentrating and disrupted sleep for the past 2 weeks. Reports occasional panic attacks, feeling overwhelmed.
- Duration, timing, location, quality, severity and context of the complaint: Increased anxiety for 2 weeks, worse in social situations at work, described as a persistent feeling of dread and nervousness. Panic attacks occur 2-3 times a week, lasting 10-15 minutes, with palpitations and shortness of breath. Severity rated 7/10 at its peak.
- Exacerbating and relieving factors, including self-management attempts and effectiveness: Exacerbated by work-related social interactions and deadlines. Relieved temporarily by listening to music and short walks. Has tried deep breathing exercises but found them only minimally effective.
- Progression of symptoms over time: Symptoms have escalated over the last fortnight, feeling more pervasive and impacting daily functioning compared to prior visit.
- Previous similar episodes, including management and outcomes: Previous episodes of anxiety and panic in early adulthood, managed with psychotherapy and a short course of sertraline. Resolved well and maintained stability for several years.
- Impact on daily activities, work and functioning: Difficulty focusing at work, leading to decreased productivity. Avoids social gatherings outside of work. Sleep disturbance (difficulty falling asleep, early waking).
- Associated focal and systemic symptoms: Palpitations, shortness of breath during panic attacks, muscle tension, headaches, fatigue.
Past Medical History:
- Relevant past medical and surgical history: Nil significant. Appendectomy at age 12.
- Relevant family history: Mother has a history of anxiety disorder and depression.
- Relevant social history including smoking, alcohol, substance use or occupational exposures: Non-smoker. Occasional alcohol consumption (1-2 units per week). Denies illicit substance use. Works as a project manager.
- Allergies and reaction details: Penicillin (rash).
- Current medications including prescribed, over-the-counter and supplements: Fluoxetine 20mg daily, prescribed by GP. Multivitamin daily. Denies OTC sleep aids.
- Immunisation history and status: Up to date with routine immunisations, including annual flu jab.
- Other relevant contributing factors: Recent promotion at work, leading to increased responsibilities and pressure.
Physical Examination:
- Vital signs: BP 120/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C.
- Physical and mental state examination findings by system:
Cardiovascular: S1/S2 normal, no murmurs.
Respiratory: Clear to auscultation bilaterally.
Neurological: Cranial nerves intact, reflexes normal, sensation intact.
Investigations:
- Completed investigations with results: Full Blood Count (FBC) – normal, Thyroid Function Tests (TFTs) – normal, ECG – normal. Conducted 3 weeks prior to this visit.
Discussion with Patient:
- Discussion of risks and benefits of medications: Discussed increasing Fluoxetine dosage and potential side effects such as nausea, insomnia, and increased anxiety initially. Patient understands and agrees to titration.
Risk Assessment:
Risk to Self:
- Current suicidal thoughts or behaviours: Denies current suicidal ideation or plans. Reports fleeting thoughts of not wanting to wake up but no intent.
- Recent suicide attempts: Denies any recent suicide attempts.
- Ongoing self-harm behaviours: Denies self-harm behaviours.
- Low mood or self-esteem concerns: Reports low mood and concerns about self-esteem due to performance anxiety.
- Changes in eating habits: Reports decreased appetite due to anxiety but no significant weight loss.
- Access to means of self-harm: Denies access to means of self-harm.
- Substance use risk: Low risk, occasional alcohol use.
Risk to Others:
- Thoughts of harming others: Denies any thoughts of harming others.
Risk from Others:
- Abuse or neglect: Denies any abuse or neglect.
- Family or environmental stressors: Increased work stress and perceived pressure from new role.
Medical Risk Factors:
- Medical risk factors: No acute medical risk factors identified.
Protective Factors:
- Support systems and anticipated positive changes: Supportive partner and close friends. Motivated to address anxiety to maintain job performance and improve quality of life.
- Engagement in therapy or supportive services: Actively engaged in current treatment.
- Absence of substance use: Maintained responsible alcohol use.
Risk Management Plan:
- Medication adjustments: Increase Fluoxetine to 40mg daily, titrating over 2 weeks. Prescribed Lorazepam 0.5mg PRN for acute panic attacks, limited to 5 doses.
- Psychological or social support options: Referral for cognitive behavioural therapy (CBT) focusing on social anxiety and stress management.
- Liaison with support services: Advised to inform HR at work if symptoms continue to impact performance, with support from occupational health.
- Safety monitoring and restriction of access to means: Not applicable; no immediate risk identified.
- Monitoring of mental state and risk: Scheduled follow-up in 2 weeks to assess medication efficacy and monitor anxiety levels.
- Crisis support options discussed: Provided details for local mental health crisis line and emergency services.
Mental Status Examination:
Appearance:
- General appearance, grooming, clothing and hygiene: Well-groomed, appropriately dressed, good hygiene.
- Signs of self-neglect or unusual physical features: No signs of self-neglect or unusual physical features.
Behaviour:
- Motor activity, eye contact and cooperation: Psychomotor activity normal, maintained good eye contact throughout, cooperative.
- Agitation, restlessness or unusual mannerisms: Appears slightly restless, fidgeting with hands occasionally.
Speech:
- Rate, volume, fluency and tone: Normal rate and volume, fluent, anxious tone.
- Speech abnormalities: No speech abnormalities.
Mood:
- Self-reported mood: "Anxious and overwhelmed."
- Observed mood: Anxious.
Affect:
- Range and appropriateness of affect: Restricted range, congruent with anxious mood.
- Congruence with mood: Congruent.
Thought:
- Thought process and content: Linear and goal-directed. Content preoccupied with work performance and social situations.
- Thought content abnormalities or unusual beliefs: No delusions, obsessions, or phobias identified.
Perception:
- Hallucinations or perceptual disturbances: Denies hallucinations or perceptual disturbances.
- Derealisation or depersonalisation: Denies derealisation or depersonalisation.
Cognition:
- Orientation, memory, attention and concentration: Oriented to person, place, and time. Remote and recent memory intact. Attention and concentration appear mildly impaired due to anxiety.
- Cognitive difficulties: Reports mild difficulties with concentration.
Insight:
- Insight into condition and need for treatment: Good insight into her anxiety and understands the need for ongoing treatment.
- Limitations in insight: No significant limitations in insight.
Judgement:
- Judgement and decision-making capacity: Judgement appears intact.
- Observed judgement concerns: No observed judgement concerns.
Impression:
- The clinician’s likely diagnosis with ICD-11 code: Generalised Anxiety Disorder (6B00), Panic Disorder (6B01.0).
- The clinician’s differential diagnoses: Adjustment Disorder with Anxious Mood, Social Anxiety Disorder.
- ADHD repeat prescription instructions: Not applicable.
Management Plan:
- Planned investigations: None at this time.
- Planned treatments: Increase Fluoxetine to 40mg daily. Lorazepam 0.5mg PRN. CBT referral.
- Other actions such as counselling, referrals or lifestyle advice: Refer to CBT, encourage stress management techniques, continue regular exercise.
- Request for GP continuation of medications: Not applicable.
Patient Summary:
- Topic or issue discussed: Increased anxiety and panic attacks related to new job role.
- Key recommendations or advice: Medication adjustment (Fluoxetine increase, PRN Lorazepam), CBT referral.
Key Takeaways:
- Key actions discussed: Increase Fluoxetine, take Lorazepam PRN, attend CBT sessions.
- Lifestyle or behavioural changes discussed: Continue exercise, practice stress management.
Next Steps:
- Follow-up actions: Review in 2 weeks to assess medication efficacy and symptom improvement.
- Actions if symptoms worsen or change: Contact practice immediately or present to A&E if suicidal thoughts develop or panic attacks become unmanageable. Use provided crisis line number.
History:
- [Date of last visit and last management plan from prior visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Symptoms present at last visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Patient age] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Whether the patient was accompanied and by whom] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Current issues, reasons for visit, and history of presenting complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Duration, timing, location, quality, severity and context of the complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Exacerbating and relieving factors, including self-management attempts and effectiveness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Progression of symptoms over time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Previous similar episodes, including management and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Impact on daily activities, work and functioning] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Associated focal and systemic symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical History:
- [Relevant past medical and surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Relevant family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Relevant social history including smoking, alcohol, substance use or occupational exposures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Allergies and reaction details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Current medications including prescribed, over-the-counter and supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Immunisation history and status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Other relevant contributing factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Examination:
- [Vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Physical and mental state examination findings by system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; separate each system on a new line.)
Investigations:
- [Completed investigations with results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Discussion with Patient:
- [Discussion of risks and benefits of medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Risk Assessment:
Risk to Self:
- [Current suicidal thoughts or behaviours] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Recent suicide attempts] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Ongoing self-harm behaviours] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Low mood or self-esteem concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Changes in eating habits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Access to means of self-harm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Substance use risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Risk to Others:
- [Thoughts of harming others] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Risk from Others:
- [Abuse or neglect] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Family or environmental stressors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medical Risk Factors:
- [Medical risk factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Protective Factors:
- [Support systems and anticipated positive changes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Engagement in therapy or supportive services] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Absence of substance use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Risk Management Plan:
- [Medication adjustments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Psychological or social support options] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Liaison with support services] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Safety monitoring and restriction of access to means] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Monitoring of mental state and risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Crisis support options discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Mental Status Examination:
Appearance:
- [General appearance, grooming, clothing and hygiene] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Signs of self-neglect or unusual physical features] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Behaviour:
- [Motor activity, eye contact and cooperation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Agitation, restlessness or unusual mannerisms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Speech:
- [Rate, volume, fluency and tone] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Speech abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Mood:
- [Self-reported mood] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Observed mood] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Affect:
- [Range and appropriateness of affect] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Congruence with mood] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thought:
- [Thought process and content] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Thought content abnormalities or unusual beliefs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Perception:
- [Hallucinations or perceptual disturbances] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Derealisation or depersonalisation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cognition:
- [Orientation, memory, attention and concentration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Cognitive difficulties] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Insight:
- [Insight into condition and need for treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Limitations in insight] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Judgement:
- [Judgement and decision-making capacity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Observed judgement concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Impression:
- [The clinician’s likely diagnosis with ICD-11 code] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer a diagnosis.)
- [The clinician’s differential diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer a diagnosis.)
- [ADHD repeat prescription instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Management Plan:
- [Planned investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Planned treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Other actions such as counselling, referrals or lifestyle advice] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Request for GP continuation of medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Patient Summary:
- [Topic or issue discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Key recommendations or advice] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Key Takeaways:
- [Key actions discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Lifestyle or behavioural changes discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Next Steps:
- [Follow-up actions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Actions if symptoms worsen or change] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
