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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.