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Patient is a 22 yo female graduated in sustainability bachelor degree , lives with parents and looking to move with her boy friend and with previous psychiatric history of ADHD and anxiety , presenting for initial psychiatric evaluation today with complaint of ADHD management and anxiety , looking to start therapy .
Current medication :
1- Lexapro 5 mg . 2 tabs po in am and one tab po at bed time
2- Atomoxetine 18 mg one cap po daily
CC: ADHD and anxiety
stressors : My recent problems are a result of my mental health conditions and my uncle passing away in October, a distressing roommate I had for a year, finishing my undergrad/starting grad school, moving apartments, and relationship problems with my mom.
Subjective :
Patient is a 22 yo female with previous psychiatric history of ADHD and anxiety, presenting for follow up and medication management today with complaint of ADHD management and anxiety, looking to start therapy, address ADHD and treatment for the depression and anxiety.
Today :
panic attacks x 2/ months, at least every other day for 20 mins to 3 hours and hyperventilates and crawling in her skin and is irritable discussed xanax as needed, start buspar and increase lexapro , agreed
started therapy , weekly , reports therapist is a good fit and she reports it ahs been helpful and journaling . Angela Grau, LCSW.
ADHD : take atomoxetine , , tolerating meds well, able to stay on task and focus
appetite is stable, snacking less , sleep at baseline
anxiety still feel sweaty hand like panic attacks —>will increased Lexapro to 15, C/o sweating , –> resolved
less mood swings
denied SI

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