Follow-up Appointment (utilising context tab for prev session notes)

Key findings from last session: - Patient reported experiencing increased anxiety levels, particularly in social settings. - Noted improvement in sleep patterns with the introduction of a nightly routine. Subjective: - The patient is visiting to address ongoing anxiety issues, particularly in social situations. - Symptoms have been present for approximately 6 months, with increased severity over the past 2 months. - The patient reports that deep breathing exercises have provided some relief, but symptoms persist. - Symptoms have worsened over time, with more frequent episodes of anxiety. - Previous episodes of anxiety were managed with cognitive behavioral therapy, which was partially effective. - The anxiety significantly impacts the patient's ability to participate in social activities and affects work performance. - Associated symptoms include occasional heart palpitations and sweating during anxiety episodes. Objective: - Vitals signs: Blood pressure 120/80 mmHg, heart rate 78 bpm. - Mental state examination: Patient appears anxious, with a tense posture and fidgeting. Assessment: - Likely diagnosis: Generalized Anxiety Disorder. - Differential diagnosis: Social Anxiety Disorder. Plan: - Investigations planned: None at this time. - Treatment planned: Continue with cognitive behavioral therapy sessions weekly. - Relevant other actions: Referral to a psychiatrist for medication evaluation.