19 Sep 2022
Patient’s Name: C. G.
Ethnicity: Hispanic/Latino
Gender: Female
Age: 54
Diagnosis: MDD F33.1 MDD, recurrent, moderate
54 y/o Female with history of anxiety and depression. Patient states “I am feeling tired, I have poor energy”. Symptoms of depression continue to be described. Anergia is described by patients. She reports episodes of excessive fatigue. She describes excessive worrying about functional decline. She reports having feelings of hopelessness. Patient is less social. Difficulty concentrating is described, patient is feeling anxious. She reports no hallucinations, delusions, or other symptoms of psychosis. Denies suicidal thoughts or ideations. Fluoxetine 10mg PO daily. Follow up appt in 4 weeks