IDENTIFICATION OF PATIENT: , The patient is a 34-year-old Caucasian female.,CHIEF COMPLAINT:,  Depression.,HISTORY OF PRESENT ILLNESS:,  The patient's depression began in her teenage years.  Sleep has been poor, for multiple reasons.  She has obstructive sleep apnea, and has difficulties with a child who has insomnia related to medications that he takes.  The patient tends to feel irritable, and has crying spells.  She sometimes has problems with motivation.  She has problems with memory, and energy level is poor. Appetite has been poor, but without weight change.  Because of her frequent awakening, her CPAP machine monitor has indicated she is not using it enough, and Medicaid is threatening to refuse to pay for the machine.  She does not have suicidal thoughts.  ,The patient also has what she describes as going into a "panic mode."  During these times, she feels as if her whole body is going to explode.  She has a hard time taking a deep breath, her heart rate goes up, blood pressure is measured as higher shortly afterward, and she gets a sense of impending doom.  These spells may last a couple of hours, but once lasted for about two day.  She does not get chest pain.  These attacks tend to be precipitated by bills that cannot be paid, or being on a "time crunch." ,PSYCHIATRIC HISTORY:,  The patient's nurse practitioner had started her on Cymbalta, up to 60 mg per day. This was helpful, but then another physician switched her to Wellbutrin in the hope that this would help her quit smoking.  Although she was able to cut down on tobacco usage, the depression has been more poorly controlled.  She has used Wellbutrin up to 200 mg b.i.d. and Cymbalta up to 60 mg per day, at different times.  At age 13, the patient cut her wrists because of issues with a boyfriend, and as she was being sutured she realized that this was a very stupid thing to do.  She has never been hospitalized for psychiatric purposes.  She did see a psychologist at age 16 briefly because of prior issues in her life, but she did not fully reveal information, and it was deemed that she did not need services.  She has not previously spoken with a psychiatrist, but has been seeing a therapist, Stephanie Kitchen, at this facility.,SUBSTANCE ABUSE HISTORY:,Caffeine:  The patient has two or three drinks per day of tea or Diet Pepsi.,Tobacco:  She smokes about one pack of cigarettes per week since being on Wellbutrin, and prior to that time had been smoking one-half pack per day.  She is still committed to quitting.,Alcohol: Denied.,Illicit drugs:  Denied.  In her earlier years, someone once put some unknown drug in her milk, and she "came to" when she was dancing on the table in front of the school nurse.,MEDICAL HISTORY/REVIEW OF SYSTEMS:,Constitutional:  See History of Present Illness. No recent fever or sweats.nan