Purpose of the visit is evaluation of any significant new issues and overall functioning since last visit, effectiveness of medication, progress related to symptoms.
On assessment, patient is alert and oriented, pleasant and cooperative slight symptoms of irritability. Speech normal, engaging, attentive open to sharing feelings and thoughts.
Patient was seen couple weeks ago because of report of increased anxiety â€œI have been having a lot of mini panic attacks latelyâ€, heightened stress level related to recent stressors. Besides other life stressors like stressed by work demand lately, feels like her boss picks on her by giving her more work than other coworkers, looking for stable housing, being a single mother, patient found her biological sister from Facebook, reconnected with her, learned that her biological father has passed away recently, a father that she never met. She has mixed feeling about losing her father and adjusting to a new sister. She was however surprised to find out that her sister is dealing with same mental condition with her, increased anxiety, poor ability to handle stress. Denied any SI, no significant past trauma, denies use of recreational drugs, social drinker, no concern with eating, weight gain. . She said that her scheduled trazadone is effective in helping her sleep at night, but does not always taking it, because it makes her feel tired all the time. Reluctant as well about using her PRN Ativan for anxiety â€œunless severe panic attacksâ€.
Life stressor, coping methods reviewed, emotions feelings frustrations acknowledge and validated emotional support and positive reinforcement given. Med option discussed. Amenable to trial PRN trazadone for increased anxiety. bedtime trazadone d/c, start trazadone PRN every 6 hours as needed. Other meds options discussed to help with anxiety and mood improvement, agree with having a trial on Neurontin, scheduled dosing along with Zolof, Neurontin expect to augment effects of zolof and help improve anxiety symptoms. Will start with Neurontin 100 mg bid as a starting dose. Risk, benefits, potential side effects reviewed.
During follow up appointment
Happy with positive changes occurring in her life, found new apartment near works, mood stable. Panic attacks still present but less frequent. Agree to have PRN Ativan D/C while on Neurontin. will keep PRN trazadone for now until Neurontin takes effects. Pt verbalized understanding and agreed with the treatment plan