Spaces:
Running
Running
| Date: 6/2/2024 | |
| History: the patient, now 46, reports further improvement in her symptoms of nervousness. She has started seeing a therapist, which she finds helpful. Her sleep has improved, and she no longer experiences significant appetite loss. She has not developed any new symptoms and continues to deny systemic symptoms. | |
| ROS: Negative except as noted. | |
| PMH: No changes. | |
| PSH: None. | |
| Meds: Continues sertraline. No longer using Tylenol for headaches. | |
| FHX: No changes. | |
| Allergies: NKDA. | |
| SH: Stable home and work life. Activities and responsibilities as an English literature professor are well-managed. | |
| Physical Examination: | |
| VS: Blood Pressure: 125/80 mm Hg, Heart Rate: 88/min | |
| Gen: Appears comfortable and at ease. | |
| Neck: No changes. | |
| Heart: Unchanged. | |
| Lungs: Clear to auscultation. | |
| Psych: Noticeable improvement in mood and anxiety levels. Reports feeling more in control. | |
| Assessment/Plan: Significant improvement with sertraline and therapy. Plan to continue current management and follow up in 6 months or as needed. Discuss potential for gradually reducing medication under supervision if improvement sustains. | |