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 Smith corroborates the patient's report of increased anxiety and panic attacks, noting she has become more withdrawn and irritable at home.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.
Date: [Insert date of consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Insert patient age in years]y/o [Insert male or female], now with [Insert acute or most important issue]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medical History:
[Insert patient age in years]y/o [Insert male or female] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
# [Insert medical comorbidity]: [Insert control status and management details]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
# [Insert past surgery]: [Insert indication, date, surgeon, and complications if mentioned]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
# Allergies: [Insert specific allergy and severity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Past Psychiatric History:
# [Insert psychiatric comorbidity]: [Insert level of control and medication history]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
# Substance Use: [Insert substance and pattern of use, including quantities if stated]. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Presenting Complaint:
[Insert presenting complaint described clinically, including issue, duration, associated issues, important negatives, and alleviating or exacerbating factors.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not use direct quotations unless required for delusions or ideas of reference.)
Collateral History:
Next of Kin: [Insert name]; [Insert relationship] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Insert collateral history provided by next of kin] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
If no collateral history mentioned, omit this section entirely.
Social History:
[Insert living situation, social supports, stressors, trauma history, and firearm possession if mentioned.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Physical Examination:
BP: [Insert blood pressure in mmHg] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HR: [Insert heart rate in bpm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SATS: [Insert oxygen saturation and oxygen modality] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
T: [Insert temperature or apyrexic] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HGT: [Insert glucose in mmol/L] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Hb: [Insert haemoglobin in g/dL] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Weight: [Insert weight in kg] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Height: [Insert height in cm] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
General appearance:
[Insert general physical health appearance findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Respiratory system:
[Insert respiratory findings including air entry, adventitious sounds, and distress status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Cardiovascular system:
[Insert cardiac examination findings including heart sounds, failure status, pulse quality, rhythm, and delays] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Abdominal system:
[Insert abdominal examination findings or explicitly stated normal findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Neurological system:
[Insert neurological examination findings including GCS, orientation, pupils, and motor/sensory findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Other relevant systems:
- [Insert system]: [Insert findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Mental State Examination:
Appearance:
[Insert appearance and grooming findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Attitude:
[Insert attitude during consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Behaviour:
[Insert psychomotor behaviour findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Speech:
[Insert speech characteristics] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Affect:
[Insert affect description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Mood:
[Insert mood state] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thought Process:
[Insert thought process description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thought Content:
- Suicidal Ideation: [Insert status and details if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Homicidal Ideation: [Insert status and details if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Perception:
- Delusional Content: [Insert details if present] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Hallucinations: [Insert details if present] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Orientation:
[Insert orientation status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Functional Factors:
[Insert effects on sleep, appetite, libido, memory, and concentration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Insight and Judgement:
[Insert insight and judgement assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
[Insert clinical assessment including working diagnosis, differentials, key findings, and complications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
1. Biochemistry requested: [Insert blood work requested] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. Imaging: [Insert imaging ordered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3. STAT medication: [Insert urgent medication details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
4. Pharmacology: [Insert medication changes or new prescriptions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
5. Psychiatrist opinion or referral: [Insert advice or referral details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
6. Allied Health Referral: [Insert allied health referrals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
7. Counselled on: [Insert counselling topics discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
8. Follow-up Instructions: [Insert follow-up instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
9. Safety Plan: [Insert safety plan details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Tasks to be created:
- [Insert task] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the section entirely. Never add direct quotations except where required to give context to delusions or ideas of reference. Never come up with your own patient details, diagnoses, assessments, plans, interventions, or tasks. Use only the transcript, contextual notes or clinical note as the source of truth.)
