H & P

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.