Consult Notes

Patient Information: - John Doe - 01/15/1985 - Male - 555-123-4567 Medical History: - History of depression and anxiety - Appendectomy in 2005 - Family history of bipolar disorder Medications: - Sertraline 50mg daily - Omega-3 supplements Allergies: - Penicillin Social History: - Non-smoker - Occasional alcohol consumption - Software Engineer - Lives with spouse and two children Review of Systems: - General: Fatigue, weight gain - Cardiovascular: No chest pain or palpitations - Respiratory: No shortness of breath - Gastrointestinal: Occasional nausea - Genitourinary: No issues reported - Musculoskeletal: No joint pain - Neurological: No headaches or dizziness - Psychiatric: Increased anxiety, low mood Physical Examination: - Vital Signs: BP 120/80, HR 72, Temp 98.6°F - General Appearance: Well-groomed, appears anxious - Head, Eyes, Ears, Nose, Throat (HEENT): Normal - Cardiovascular Examination: Normal heart sounds - Respiratory Examination: Clear breath sounds - Abdominal Examination: Soft, non-tender - Musculoskeletal Examination: Normal range of motion - Neurological Examination: Alert and oriented Assessment: - Diagnosis: Generalized Anxiety Disorder - Differential Diagnosis: Major Depressive Disorder Plan: - Treatment Plan: Continue Sertraline, initiate cognitive behavioral therapy - Medications Prescribed: Sertraline 50mg daily - Follow-Up Instructions: Follow up in 4 weeks - Patient Education and Counseling: Discussed stress management techniques and importance of medication adherence