Anxiety

HISTORY:

Increased anxiety for ‍ ‍hoursdays

Described as: ‍worryfeeling on edgerestlessnessirritabilitytension

Recent stressors: ‍, ‍work-related issues, ‍personal relationship issues, ‍social issues

Severity: ‍mildmoderateseveredebilitating, ‍causingwithout causing significant distress

Negative impact on: ‍daily activitiessocial lifeworkfamilypersonal relationship

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective

‍excessive worry

‍restlessness

‍fatigue

‍depressed mood

‍difficulty concentrating

‍irritability

‍muscle tension

‍sleep disturbances

‍racing thoughts

‍sweating

‍nausea

‍suicidal thoughts, ‍persistentintermittent, ‍withwithout a plan, ‍withwithout intent to act

‍hallucinations



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Mental Status:

Appearance: ‍well-dressed, ‍well-groomed, ‍goodpoor eye contact, appears ‍age-appropriate

Behavior: ‍cooperativenon-cooperative

Psychomotor activity: ‍normalretardedagitated

Speech: ‍clear, ‍slowrapid, ‍monotonoustalkative

Mood: ‍euthymicdysthymic, ‍anxious, ‍

Affect: ‍euthymic, ‍reactivenon-reactive, ‍full range, ‍appropriate to situation, ‍congruent with mood

Thought process: ‍organizeddisorganized, ‍coherentincoherent, ‍logicalillogical, ‍

Thought content: ‍normalpreoccupationshopelessness, ‍delusions, ‍suicidal ideations, ‍homicidal ideations

Perception: ‍normal, ‍hallucinations, ‍illusions

Cognition: ‍alert, oriented to ‍3 spheres, attention ‍intactdistractible, memory ‍intactimpaired

Judgment: ‍goodmoderatepoor

Insight: ‍goodmoderatepoor into condition

Reliability: ‍goodmoderatepoor



ASSESSMENT:

‍Anxiety ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍TSH

- Urine toxicology screen

- Psychoeducation about anxiety

- Stress management techniques

- Relaxation techniques

- Regular exercise

- Healthy diet

- Sleep hygiene

- Avoidance of alcohol and drugs

- ‍Antidepressants

- ‍Anxiolytics/Sedatives

- ‍Atypical antipsychotics

- Cognitive behavioral therapy

- Referral to psychologist

- Referral to social worker

- Referral to psychiatrist

- Follow-up in ‍ ‍weeksmonths

- Return if condition worsen or if new symptoms develop such as suicidal thoughts