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.