Week 2 Client Information: Patient is 28-year-old African American female who present to the clinic for a follow-up visit. The patient reported that she has been in compliance with her medications, and she is currently in her 3rd year in college and the patient is majoring in computer science. The patient lives alone and is currently in a long-distance relationship. Visit Information: The patient reported “I am getting panic attack due to the stress of going back to school.” Practice Management: The patient medication includes Bupropion HCL 150 mg oral tablet once daily, Duloxetine HCL 60 mg oral capsule once daily, Hydroxyzine 50 mg oral tablet as needed. Diagnosis: (F41.9) anxiety disorder unspecified, (F60.9) Personality disorder, unspecified Treatment Plan and Notes: Patient is alert and oriented x3, pleasant and interactive with good tone of voice. She denies SI/HI/AH/VH. The patient endorsed experiencing panic attacks and increased anxiety due to school activities and she

Week 2

 

Client Information: Patient is 28-year-old African American female who present to the clinic for a follow-up visit. The patient reported that she has been in compliance with her medications, and she is currently in her 3rd year in college and the patient is majoring in computer science. The patient lives alone and is currently in a long-distance relationship.

Visit Information: The patient reported “I am getting panic attack due to the stress of going back to school.”

Practice Management: The patient medication includes Bupropion HCL 150 mg oral tablet once daily, Duloxetine HCL 60 mg oral capsule once daily, Hydroxyzine 50 mg oral tablet as needed.

Diagnosis: (F41.9) anxiety disorder unspecified, (F60.9) Personality disorder, unspecified

Treatment Plan and Notes: Patient is alert and oriented x3, pleasant and interactive with good tone of voice. She denies SI/HI/AH/VH. The patient endorsed experiencing panic attacks and increased anxiety due to school activities and she feels overwhelmed with assignment deadlines. The patient reported that she has been compliant with Bupropion with Duloxetine and also Hydroxyzine PRN which has been effective in controlling her symptoms. The patient denies experiencing side effects or adverse effects of the medications. The patient was encouraged to continue taking her medications and educated to report adverse effects to the provider and the patient verbalized understanding. Medication refill sent to the patient's preferred pharmacy. Patient to follow up in 2-4 weeks.

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