Patient Name: John Smith

MRN: XXX

Date of Service: 07-25-2023

Start Time: 09:30 End Time: 10:30

Billing Code(s): 90791, 90834

Accompanied by: None

CC: Follow-up for generalized anxiety disorder and panic attacks

HPI: Mr. Smith is a 40-year-old male who was admitted to the inpatient mental health unit due to severe anxiety and recurrent panic attacks. During his hospitalization, he received individual therapy and participated in relaxation and stress management group sessions. Since his discharge, he reports some improvement in anxiety but still experiences frequent panic attacks. He mentions feeling constantly worried and on edge, often struggling to concentrate or relax. Mr. Smith has trouble falling asleep and frequently wakes up in the middle of the night.

Crisis: Mr. Smith denies any suicidal or homicidal thoughts and states that he seeks help to find better ways to cope with his anxiety and panic attacks.

Reviewed Allergies: NKA

Current Drugs: Sertraline 50mg daily

ROS:

Constitutional: Patient reports difficulty sleeping, fatigue, and appetite changes.

Eyes: Normal.

ENT: No hearing loss or tinnitus.

Cardiac: No chest pain or palpitations.

Respiratory: No shortness of breath.

GI: No nausea, vomiting, or gastrointestinal changes.

GU: No urinary symptoms.

Musculoskeletal: No joint pain or muscle weakness.

Skin: No rashes or itching.

Neurologic: No headaches, dizziness, or numbness/tingling.

Endocrine: No excessive thirst or heat/cold intolerance.

Hematologic: No history of bleeding or easy bruising.

Allergy: No known allergies to medications or environmental factors.

Reproductive: Not applicable.

O-

Vitals: T 98.2°F, P 74 bpm, R 16 breaths per minute, BP 130/80 mmHg

PE:

Heart: Regular rate and rhythm, no murmurs or gallops.

Lungs: Clear to auscultation bilaterally.

Skin: No rashes or lesions noted.

Abdomen: Soft and non-tender.

Neurological: Alert and oriented to time, place, and person.

Labs: CBC, electrolytes, and TSH are within normal limits.

Results of any Psychiatric Clinical Tests: Generalized Anxiety Disorder 7 (GAD-7) score: 18 (severe anxiety)

MSE:

John Smith, a 40-year-old male, presented with a tense demeanor and frequent signs of restlessness. He expressed feelings of excessive worry and fear about various aspects of his life. Mr. Smith reported that his anxiety is often accompanied by physical symptoms such as rapid heartbeat, trembling, and sweating, consistent with panic attacks. During the session, he appeared preoccupied with anxious thoughts and had difficulty staying focused on the conversation. Mr. Smith denied any hallucinations or delusions. He demonstrated intact memory and cognitive function. His insight into his condition was fair, but his judgment appeared to be mildly impaired due to the impact of anxiety on decision-making.

A –

Definitive Diagnosis:

Generalized Anxiety Disorder (GAD) (ICD-10 code: F41.1) (DeMartini et al., 2019)

John Smith is diagnosed with GAD. His continuous and excessive stress and anxiety about numerous elements of life, lasting over six months and considerably hurting his everyday functioning, led to this diagnosis. GAD meets DSM-5TR criteria.

The DSM-5TR requires at least six months of excessive anxiety and concern about a variety of events or activities to diagnose GAD. Restlessness, weariness, difficulties focusing, impatience, muscular tension, and sleep disruptions are related with anxiety, and the person has trouble controlling it (DeMartini et al., 2019).

John’s DSM-5TR GAD symptoms include excessive anxiety and dread, somatic symptoms such restlessness and sleep difficulties, and trouble focusing. Generalized Anxiety Disorder (GAD) was diagnosed because his anxiety severely impairs everyday living.

Differential Diagnoses:

· Panic Disorder (ICD-10 code: F41.0) (Oussi et al., 2023)

· Adjustment Disorder with Anxiety (ICD-10 code: F43.22) (O’Donnell et al., 2019)

· Social Anxiety Disorder (ICD-10 code: F40.10)

Panic Disorder: Panic attacks are abrupt, acute bouts of terror or discomfort that last minutes. Panic episodes may include palpitations, sweating, shaking, shortness of breath, chest discomfort, and a fear of losing control or dying. Panic Disorder is characterized by sudden panic episodes and concern about them (Oussi et al., 2023).

Rationale for Ruling Out Panic Disorder: John Smith has repeated panic attacks, but his main symptom is excessive concern and anxiety. He feels anxious and tense, which is typical with GAD. John does not worry about future episodes, which is a DSM-5TR criterion for Panic Disorder.

Adjustment Disorder with Anxiety: An recognized stressor or life event causes emotional or behavioral symptoms in Adjustment Disorder. Adjustment Disorder with Anxiety entails excessive anxiety and concern in reaction to stress. Restlessness, impatience, trouble focusing, and sleep disruptions may occur (O’Donnell et al., 2019).

Rationale for ruling out Adjustment Disorder with Anxiety:

John’s symptoms have lasted longer than anticipated for an adjustment disorder, despite his hospitalization and worry. After stressor removal or management, Adjustment Disorder usually resolves. John’s long-term and severe anxiety symptoms reflect Generalized Anxiety Disorder.

Social Anxiety Disorder: Also called as Social Phobia, this disorder causes great dread or anxiety in social settings where the person may be judged. People avoid or suffer through social settings out of fear of shame or disgrace (Koyuncu et al., 2019).

Reason for Ruling Out Social Anxiety Disorder: John’s anxiety seems to be more widespread, impacting many facets of his life, rather than just social settings. He doesn’t discuss social anxiety disorder’s performance and scrutiny anxieties. His anxiety is more like Generalized Anxiety Disorder, with persistent concern, restlessness, and difficulty working.

John Smith’s DSM-5TR diagnosis is Generalized Anxiety Disorder (GAD). GAD fits his symptoms of excessive worry, constant anxiety, and impaired functioning, while Panic Disorder, Adjustment Disorder with Anxiety, and Social Anxiety Disorder were ruled out due to specific features that did not match his clinical picture.

P –

Pharmacological Tx:

Increase sertraline dosage to 100mg daily to target anxiety and panic symptoms more effectively (Carl et al., 2019).

Consider adjunctive therapy with a low-dose benzodiazepine (e.g., lorazepam) for short-term relief of acute anxiety or panic attacks (Carl et al., 2019).

Non-pharmacological Tx:

I encouraged the patient to continue individual therapy to address underlying causes of anxiety and panic attacks (DeMartini et al., 2019).

I implemented Cognitive-Behavioral Therapy (CBT) to challenge and reframe anxious thoughts, promote relaxation techniques, and develop coping strategies for panic attacks (Borza, 2022).

I encouraged the patient to do regular physical exercise as a means to reduce anxiety and promote overall well-being.

I taught the patient stress management techniques, including deep breathing exercises and mindfulness practices (DeMartini et al., 2019).

I educated on sleep hygiene to improve sleep quality and reduce nighttime anxiety (DeMartini et al., 2019).

Education:

• I gave psychoeducation about Generalized Anxiety Disorder, its symptoms, and treatment alternatives (DeMartini et al., 2019).

• I warned the patient about sertraline dosage increase negative effects.

• I taught grounding and progressive muscle relaxation for anxiety and panic (DeMartini et al., 2019).

I stressed medication adherence and counseling attendance.

• I educated on benzodiazepine usage, dependency, and acute symptom relief.

• I recommended anxiety management workbooks and apps (DeMartini et al., 2019).

•I stressed that caffeine and other stimulants worsen anxiety symptoms.

• I stressed the significance having a robust support system and requesting assistance from friends, family, and support groups (DeMartini et al., 2019).

Follow-up: Two weeks after medication modification and counseling to determine patient response.

Referrals: None at this time.

References

Borza, L. (2022). Cognitive-behavioral therapy for generalized anxiety.
Generalized Anxiety Disorders,
19(2), 203–208. https://doi.org/10.31887/dcns.2017.19.2/lborza

Carl, E., Witcraft, S. M., Kauffman, B. Y., Gillespie, E. M., Becker, E. S., Cuijpers, P., Van Ameringen, M., Smits, J. A. J., & Powers, M. B. (2019). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials.
Cognitive Behaviour Therapy,
49(1), 1–21. https://doi.org/10.1080/16506073.2018.1560358

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder.
Annals of Internal Medicine,
170(7), ITC49. https://doi.org/10.7326/aitc201904020

Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges.
Drugs in Context,
8(8), 1–13. https://doi.org/10.7573/dic.212573

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment Disorder: Current Developments and Future Directions.
International Journal of Environmental Research and Public Health,
16(14), 2537. https://doi.org/10.3390/ijerph16142537

Oussi, A., Hamid, K., & Bouvet, C. (2023). Managing emotions in panic disorder: A systematic review of studies related to emotional intelligence, alexithymia, emotion regulation, and coping.
Journal of Behavior Therapy and Experimental Psychiatry, 101835. https://doi.org/10.1016/j.jbtep.2023.101835