examples/note2.txt

Date: 3/18/2024
History: the patient, a 45-year-old female, returns for a follow-up regarding her nervousness. She reports a slight improvement in her symptoms with reduced intensity of nervousness on Sunday nights and Monday mornings. However, she still experiences difficulty sleeping and occasional lack of appetite. She has tried meditation and deep breathing exercises, which have provided minimal relief. No new symptoms have emerged since the last visit. She continues to deny fevers, chills, nausea, or other systemic symptoms.
ROS: Negative except as noted.
PMH: No changes.
PSH: None.
Meds: Tylenol for occasional headaches. Started on a trial of low-dose sertraline since the last visit.
FHX: No changes.
Allergies: NKDA.
SH: No changes in social circumstances. Continues to work as an English literature professor.
Physical Examination:
VS: Blood Pressure: 128/82 mm Hg, Heart Rate: 92/min
Gen: Appears more relaxed than the previous visit.
Neck: No changes.
Heart: Unchanged.
Lungs: Clear to auscultation.
Psych: Appears slightly more at ease, maintains good eye contact, speech and thought process remain coherent.
Assessment/Plan: Improvement noted with sertraline. Will continue the current dose and re-evaluate in 3 months. Encouraged to continue non-pharmacological interventions like meditation and deep breathing exercises. Consider referral to therapy for additional support.