Professional Documents
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osce-stations.blogspot.com/2018/02/hollys-anxiety.html
Occupation Housewife
History I am fit and well. I recently moved to this area with my husband and my
son and I am now registered to this practice. I do not have any medical
illness as far as I am concerned. Always fit and well.
[Only if asked] The attack comes in episodes and it happens out of the
blue and came unprovoked. It stops after 10 minutes or so but it’s
difficult to get the timing right when I was in that state. It’s the worst
feeling ever, and I wouldn’t wish my worst enemy to go through that. I
find it difficult to concentrate because I keep worrying that the ‘episode’
will come back.
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Introduction & consent
Expectations "Is there anything in particular you were hoping we would to today?"
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Gives reasonable differential diagnosis (Panic attack disorder, GAD, Depression,
Organic)
Management point:
Consider how the patient was dispensed with a 2-month supply of lorazepam
(benzodiazepine). It is classed as a controlled drug and it should not be prescribed more
than 30 days, unless in special circumstances. Most NHS trusts do not go beyond 14
days for prescriptions of controlled drugs.
Advise and education is important as psychoeducation improves patients’
understanding of their own illness.
A referral for psychotherapy such as cognitive behavioural therapy might benefit some
patients.
Other medications such as antidepressants and beta blockers can help to control the
unpleasant adrenergic symptoms of panic attacks. Benzodiazepines are used to bridge
the therapy until the antidepressant takes effect but often it should not be part of the
long-term maintenance therapy. Expert psychiatry input can be sought regarding
commencement and dosing of the medications.
Top differentials:
1. Panic disorder – characterised by episodes of unprovoked anxiety attacks like in this
history rather than constant feelings of anxiety as in GAD.
2. Generalised anxiety disorder – often, the feeling of anxiety spans a continuous duration
of time in GAD
3. Depression – if symptoms of affective disorders, ie depression preceded the panic
attack or the criteria for diagnosis has been fulfilled, diagnosis of depression takes
precedence.
4. Substance abuse – withdrawal symptoms can often mimic episodic panic attacks
5. Organic disorders – endocrine disorders such as phaeochromocytoma, paraganglioma,
and carcinoid syndrome could mimic panic attacks.
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