Posted: August 5th, 2023

Follow-up for generalized anxiety disorder and panic attacks

Patient Name: Peter K
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 Helpance 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

Patient Name: Peter K
MRN: XXX
Date of Service: 07-25-2023
Start Time: 09:30 End Time: 10:30
Billing Code(s): 90791, 90834
Accompanied by: None
Chief Complaint (CC): Follow-up for generalized anxiety disorder and panic attacks

History of Present Illness (HPI):
Mr. Smith, a 40-year-old male, was admitted to the inpatient mental health unit due to severe anxiety and recurrent panic attacks. Despite receiving individual therapy and participating in relaxation and stress management group sessions during his hospitalization, he still experiences frequent panic attacks and constant worry. He reports difficulty sleeping, fatigue, appetite changes, and waking up in the middle of the night.

Crisis Assessment:
Mr. Smith denies any suicidal or homicidal thoughts. His main goal is to find better ways to cope with his anxiety and panic attacks.

Review of Systems (ROS):
No significant findings in the constitutional, eyes, ENT, cardiac, respiratory, GI, GU, musculoskeletal, skin, neurologic, endocrine, hematologic, allergy, or reproductive systems.

Objective Assessment (O-):
Vital signs are within normal limits: T 98.2°F, P 74 bpm, R 16 breaths per minute, BP 130/80 mmHg.

Physical Examination (PE):
The physical examination shows a regular heart rate and rhythm, clear lungs on auscultation, no rashes or lesions on the skin, a soft and non-tender abdomen, and the patient is alert and oriented to time, place, and person.

Psychiatric Clinical Test Results:
The Generalized Anxiety Disorder 7 (GAD-7) score is 18, indicating severe anxiety.

Mental Status Examination (MSE):
Mr. Smith presents with a tense demeanor and restlessness. He expresses excessive worry and fear about various aspects of his life and reports physical symptoms consistent with panic attacks. During the session, he struggles to stay focused on the conversation due to preoccupation with anxious thoughts. No hallucinations or delusions are reported, and memory and cognitive function appear intact. Insight into his condition is fair, but judgment is mildly impaired due to anxiety.

Assessment (A-):
Definitive Diagnosis:
Mr. Smith is diagnosed with Generalized Anxiety Disorder (GAD) (ICD-10 code: F41.1). His symptoms of excessive anxiety and worry about various aspects of life, lasting over six months and significantly impairing daily functioning, meet the criteria for GAD in DSM-5TR (DeMartini et al., 2019).

Differential Diagnoses:
Other potential diagnoses considered were Panic Disorder (ICD-10 code: F41.0), Adjustment Disorder with Anxiety (ICD-10 code: F43.22), and Social Anxiety Disorder (ICD-10 code: F40.10). However, these were ruled out due to specific features that did not match Mr. Smith’s clinical presentation.

Treatment Plan (P-):
Pharmacological Treatment:
The sertraline dosage will be increased to 100mg daily to target anxiety and panic symptoms more effectively (Carl et al., 2019). Additionally, adjunctive therapy with a low-dose benzodiazepine (e.g., lorazepam) will be considered for short-term relief of acute anxiety or panic attacks (Carl et al., 2019).

Non-pharmacological Treatment:
Mr. Smith will continue individual therapy to address underlying causes of anxiety and panic attacks (DeMartini et al., 2019). Cognitive-Behavioral Therapy (CBT) will be implemented to challenge and reframe anxious thoughts, promote relaxation techniques, and develop coping strategies for panic attacks (Borza, 2022). Regular physical exercise will be encouraged to reduce anxiety and promote overall well-being. Stress management techniques, including deep breathing exercises and mindfulness practices, will be taught (DeMartini et al., 2019). Mr. Smith will receive education on sleep hygiene to improve sleep quality and reduce nighttime anxiety (DeMartini et al., 2019).

Education:
Psychoeducation about Generalized Anxiety Disorder, its symptoms, and treatment alternatives will be provided (DeMartini et al., 2019). Mr. Smith will be informed about potential negative effects of the sertraline dosage increase. Grounding and progressive muscle relaxation techniques will be taught for anxiety and panic (DeMartini et al., 2019). Medication adherence and counseling attendance will be emphasized. Education on benzodiazepine usage, dependency, and acute symptom relief will be provided. Mr. Smith will be recommended anxiety management workbooks and apps (DeMartini et al., 2019). The significance of having a robust support system and seeking Helpance from friends, family, and support groups will be stressed (DeMartini et al., 2019).

Follow-up:
A follow-up appointment will be scheduled two weeks after the medication modification and counseling to assess Mr. Smith’s response to the treatment plan.

Referrals:
No referrals are required 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

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