Spaces:
Running
Running
| Date: 12/29/2024 | |
| History: the patient comes in for a scheduled follow-up. She feels much better and has managed to maintain her improvements. She expresses a desire to start tapering off sertraline under medical supervision. No new health concerns have been noted. She remains active at work and home. | |
| ROS: Entirely negative. | |
| PMH: No changes. | |
| PSH: None. | |
| Meds: Sertraline, with a plan to taper. | |
| FHX: No changes. | |
| Allergies: NKDA. | |
| SH: Stable and positive home and work environment. | |
| Physical Examination: | |
| VS: Blood Pressure: 122/78 mm Hg, Heart Rate: 84/min | |
| Gen: Looks healthy and content. | |
| Neck: No changes. | |
| Heart: Unchanged. | |
| Lungs: Clear. | |
| Psych: Maintained improvement in mental health. Ready for gradual medication reduction. | |
| Assessment/Plan: Patient has shown sustained improvement and is interested in tapering off medication. Will initiate a slow tapering process of sertraline and monitor closely for any recurrence of symptoms. Continue therapy and supportive measures. Next follow-up scheduled in 3 months to assess progress. | |