Psychiatric Note

Specialty: General Practitioner Date: 01 November 2024 45y/o female, now with escalating anxiety and recent panic attacks. Medical History: 45y/o female # Hypertension: Well-controlled on Ramipril 5mg daily. Last BP check 1 month ago, 128/78 mmHg. # Cholecystectomy: Indication - symptomatic gallstones, date - 10/03/2018, surgeon - Dr. Thomas Kelly, complications - none. # Allergies: Penicillin (hives, rash). Past Psychiatric History: # Generalised Anxiety Disorder: History of GAD since early adulthood, managed with CBT in the past, currently unmedicated. Recent increase in symptoms. # Substance Use: Social alcohol use, 2-3 units per week. Denies illicit drug use or tobacco. Presenting Complaint: Patient reports a significant increase in anxiety over the past three months, escalating to daily panic attacks in the last two weeks. Symptoms include palpitations, shortness of breath, dizziness, and a feeling of impending doom, lasting typically 10-15 minutes. She notes these attacks are often triggered by work-related stress but can also occur spontaneously. She denies chest pain, focal neurological deficits, or suicidal ideation. Alleviating factors include deep breathing exercises, but these are becoming less effective. Exacerbating factors include high-pressure work situations and lack of sleep. Collateral History: Next of Kin: John Smith; Husband Mr. Smith corroborates the patient's report of increased anxiety and panic attacks, noting she has become more withdrawn and irritable at home. He is concerned about her reduced appetite and difficulty sleeping. Social History: Lives with her husband and two teenage children in a semi-detached house. Works as a marketing manager, reporting significant job-related stress. Social supports include her family and a small circle of friends. Reports no history of significant trauma. Denies firearm possession. Physical Examination: BP: 132/84 mmHg HR: 88 bpm SATS: 98% on room air T: Apyrexic HGT: 5.6 mmol/L Hb: 13.5 g/dL Weight: 72 kg Height: 165 cm General appearance: Well-nourished, well-groomed female, appears anxious and somewhat fatigued. Respiratory system: Clear air entry bilaterally, no adventitious sounds. No signs of respiratory distress. Cardiovascular system: S1 S2 dual, no murmurs. No peripheral oedema. Pulses palpable and strong, regular rhythm. Abdominal system: Soft, non-tender, non-distended. Bowel sounds present. Neurological system: GCS 15. Oriented to person, place, and time. Pupils equal and reactive to light. No focal motor or sensory deficits. Mental State Examination: Appearance: Well-groomed, dressed appropriately for the weather. Appears tired, with some psychomotor agitation, fidgeting hands. Attitude: Cooperative, but visibly distressed and tearful at times. Behaviour: Restless, with occasional hand wringing. Maintained good eye contact. Speech: Normal rate and rhythm, clear articulation. Content is coherent but dominated by anxiety. Affect: Anxious, restricted, congruent with mood. Mood: "Overwhelmed and constantly on edge." Thought Process: Linear and goal-directed, but with prominent themes of worry and future-oriented concerns. Thought Content: - Suicidal Ideation: Denies suicidal ideation. - Homicidal Ideation: Denies homicidal ideation. Perception: - Delusional Content: Denies any delusional content. - Hallucinations: Denies any hallucinations. Orientation: Oriented to person, place, and time. Functional Factors: Reports difficulty falling and staying asleep, averaging 4-5 hours per night. Appetite is reduced, often skipping meals due to nausea. Libido decreased. Reports significant difficulty concentrating at work and poor memory for recent events. Insight and Judgement: Good insight into her anxiety symptoms and their impact on her life. Judgement appears intact. Assessment: 45-year-old female presenting with exacerbated Generalised Anxiety Disorder and new-onset panic disorder. Key findings include increased worry, panic attacks with somatic symptoms, sleep disturbance, and reduced appetite. Differential diagnoses include thyroid dysfunction (though recent bloods normal), cardiac arrhythmias (denied chest pain, ECG normal 6 months ago), and other primary psychiatric disorders. Stressors appear to be work-related and lack of self-care. Risks include further functional impairment and potential for development of depressive symptoms. Plan: 1. Biochemistry requested: Full blood count, thyroid function tests, electrolytes, liver function tests, HbA1c. 2. Imaging: None. 3. STAT medication: Lorazepam 0.5mg PRN for severe panic attacks (limited supply, discussed potential for dependence). 4. Pharmacology: Commence Escitalopram 10mg once daily, titrate after 2 weeks if tolerated. Advised on potential side effects and delayed onset of action. 5. Psychiatrist opinion or referral: Referral to community mental health team for psychiatric assessment and consideration of psychological therapies (CBT). 6. Allied Health Referral: Recommended gentle exercise, mindfulness apps. 7. Counselled on: Importance of regular sleep hygiene, reducing caffeine intake, stress management techniques, and avoiding social isolation. Discussed medication benefits and risks. 8. Follow-up Instructions: Review in 2 weeks to assess medication efficacy and side effects. Advised to contact surgery if symptoms worsen or new concerns arise. 9. Safety Plan: Patient aware of crisis lines and emergency services if feeling overwhelmed or unsafe. Tasks to be created: - Send referral to Community Mental Health Team. - Prescribe Escitalopram 10mg, 28 tablets. - Prescribe Lorazepam 0.5mg, 5 tablets.