Sample Clinical Assessment Report

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SAMPLE CLINICAL ASSESSMENT REPORT

identification data
Name: Johan Dollah
Age: 35
Date of birth: 16 February 1976.
Sex : Male
Race: Malay
Education: Degree in Computer Science, Australia
Occupation: Computer programmer at NEXIS Communications
Marital Status: Married with three children

pROBLEM
Chief Complaint
Mr Johan experiences symptoms of panic attack when he feels self-conscious in front of other people when performing certain tasks. He reported feeling faint and had black out of thoughts during those episodes, whereby he was not able to think of anything. Both his hands would tremble and become numb. He would also be sweating but experienced no symptoms of pounding heart or choking sensations. Those panic symptoms would often last for one to two hours or until he removed himself from the anxiety provoking situation.

Reason for Referral
The patient was referred for psychotherapy to control his panic symptoms.

History of Presenting Illness
The patient began feeling conscious of people around him when he was around 17. Before that, he was not concerned with what people thought of him. He could not explain the cause for the gradual change in behaviour. When younger, he would often climb trees and swim in rivers without fear of endangering himself. However, as he turned 17, he began to fear accidents and the injuries that they might cause. He was unable to recall any significant event in his life that might have influenced his condition.

He said that he had no severe feelings of anxiety when he was studying in Australia. There were occasional feelings of nervousness when he had to do class presentation, but he described those reactions as normal and he was able to overcome them. It was only when he returned home to Malaysia and started working when he began to develop those strong feelings of anxiety when he had to deal with his colleagues. He would always try to avoid any workshops or seminars in which there would be role-playing exercises where he would very likely be the centre of attention. He mentioned having fear of doing something embarrassing and that people would think that he is abnormal. He also tried to avoid wedding ceremonies or any social functions where he would be likely to encounter a lot of people he does not know. Nevertheless, the panic symptoms were not too severe at that time. He was still able to overcome them by either avoiding such events, or, when avoidance was not possible, by forcing himself to go through those anxiety provoking situations without a full-blown panic attack, although with much distress.

His panic attacks became more troublesome two years ago, after he was involved in two motor vehicle accidents within one week. The first road accident was mild in which he tried to avoid hitting a dog in the middle of the road but went over a pavement. Fortunately there was no one walking on the pavement at that time.

The second was more severe in which he could have lost his life when his lost control of his car and smashed into a road divider. It was raining when both accidents happened. This time the accident caused many onlookers to gather around the scene of the accident. There were many people surrounding and looking at him. It was then that he first felt his hands trembling and his thoughts going blank. He was badly shaken by the accident and would still feel a little jittery whenever he happens to be driving and it rains. He would experience occasional flashbacks of the accident particularly when he was driving in the rain.

Since the second accident, his panic attacks became more frequent and intense. However, his panic symptoms are not always present whenever he is in front of a group of people. The panic attack will only occur when he is conscious of being observed, such as having to do an oral presentation in front of strangers whose eyes are on him or...
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