Pt Name: L.G.D Age: 30 Years old.
Diagnosis: Generalized Anxiety Disorder / Insomnia / Major Depressive Disorder/ PTSD
Chief Complain: Still having panic attack. Pt is a 30 year old female, who presented to the clinic complaining that she is still having panic attack and that Fluoxetine is not helping her though it helped her to loss the weight she gained from taking Lexapro. She is having problem trying to impress people at work by trying to make them see her as a normal person which is affecting her performance. Her anxiety level is 8/10 while her depression level is 5/10. Pt denied any SI/HI/AU/VH intent. Pt uses Xanax in the morning to keep her anxiety level down and some times takes it in the afternoon. Pt’s list of medications include Alprazolam (Xanax) 1 MG Oral Tablet Fluoxetine HCl (FLUoxetine HCl) 10 MG Oral Capsule Fluoxetine HCl (FLUoxetine HCl) 20 MG Oral Capsule. Pt’s med was called in and pt is to follow up in a months time.