INITIAL EXAM
SYMPTOMS: Patient has been dealing with anxiety, depression, insomnia and fatigue for his whole life.
At its worst, he rates the intensity of the discomfort of his condition a 10/10, and affects his life on a daily basis. He is currently on medication (Alprazolam and Celexa) for his anxiety and depression.
His health problems affect every area of life including work, family, and hobbies. He was in a STEM career, but currently has not been feeling well enough to go to work and is on disability. He also does not have energy to do house work or to partake in tennis or exercise.
In his initial exam, he states that in the past three years his depression has gotten very bad and started taking his current medication. For the past 8 months he has been doing well, but a couple of months ago started having trouble getting out of bed. He often wakes up in the morning feeling sick, nausea, and irritability. He feels he can not function well. He also often gets headache and feels sadness.
AFTER TREATMENT
One month into the treatment he states his stomach and headaches have been feeling better, and his nausea is doing better, but while his overall morning feeling is a bit better, his sadness and fatigue is still there. He has seen improvements in his energy while being able to do more in the house.
Two months and a few more weeks later, he states that he has been able to get up at earlier times (9:00 AM to 10:00AM) and has been feeling good for the last few days. He no longer has the shaky feeling. He has been able to be more active, and even gets out to walk his dog now. His bowel movements have been better, although it is still not always solid. It takes him two to three hours to fall asleep still and he still gets up to go to the restroom in the middle.
Five months into treatment, he states his sleep is definitely much better. He still wakes up to use the restroom, but is not waking up as much, and feels overall is staying asleep better.
