Panic attack disorder

ANSWER

This is a clinical report using a follow-up visit template for a 32-year-old woman with panic attack disorder.

Clinical Report
Name of the patient: [Fictitious Name]
Visit Date: [Insert Date]
32 years old
Gender: female
Panic Attack Disorder (F41.0) is the diagnosis.

Chief Complaint (CC): “An update regarding my panic episodes. Lately, I’ve been feeling better.

History of Present Illness (HPI): Two years ago, the patient, a 32-year-old woman, was diagnosed with panic attack disorder. She’s here for a planned follow-up appointment. Over the last three months, she reports that her symptoms have stabilized. According to the patient, the number of panic attacks has dropped from three to four episodes per week to one or two moderate events per month.

She reports that she occasionally experiences dizziness, palpitations, and shortness of breath under stressful situations, but that these symptoms go away faster than they used to. The patient has complied with both her psychotherapy and her prescription drugs. Since her last appointment, she denies experiencing any major disruptions in her day-to-day activities or encountering any new pressures.

Past Psychiatric History (PPH): Panic Attack Disorder was diagnosed two years prior.
Treatment consists of cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) therapy.
Medical History (PMH): No serious illnesses were mentioned.
History of Society:
Living arrangement: She shares a home with her spouse.
Employment: I’m a graphic designer full-time.
Substance abuse: Disavows the use of alcohol, tobacco, or recreational drugs.
Support network: Strong social and familial ties.
Presently taking 50 mg of sertraline once daily.
For acute symptoms, use 0.5 mg of lorazepam as needed (about twice a month).
Assessment of Mental Status (MSE):
Look: Well-groomed, dressed casually.
Behavior: Calm and cooperative.
Speech: Typical tone and pace.
“Feeling good and optimistic” is the mood.
Influence: Proper.
Goal-oriented and logical thought process.
Content of thought: Disavows thoughts of suicide or murder.
Cognitive: Aware and cognizant of time, place, and people.
Good judgment and insight.
Evaluation: The patient has a stable case of panic attack disorder. By using healthy coping strategies and sticking to her treatment plan, she has demonstrated a notable improvement in the frequency and severity of her panic attacks. There were no documented drug side effects. Both her personal and professional lives are going well for her.

Plan: Drugs:

Keep taking 50 mg of sertraline every day.
Continue taking 0.5 mg of lorazepam PRN, but keep a careful eye on your dosage to avoid reliance.
Psychoanalysis:

Maintain your regular CBT sessions, concentrating on coping with triggers and lingering stress.
Changes in Lifestyle:

Promote relaxing methods (such as yoga and mindfulness).
A balanced diet and regular exercise are essential.
Learning:

Stress the value of consistent medication use and routine check-ups.
Teach the patient how to spot the early indicators of worsening panic attacks.
Follow-up:

Unless symptoms increase, schedule the next appointment for three months from now.
Signature: [Name, Qualifications]
[Your Role]
[Date]

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