Primary Care Mental Health Follow-Up Note

HPI

• 34 yo F (DOB: 14/05/1990, MRN: 492-817-33) presents at 14:15 CST for 4-week f/u of MDD and GAD. Started sertraline 4 weeks ago. Reports ~30 % improvement in baseline mood, but persistent work-related worry and initial insomnia. Tolerating med well; mild transient nausea resolved after week 1. PHQ-9 today is 12 (down from 17); GAD-7 is 11 (down from 15).
• PMH: Mild intermittent asthma, hypothyroidism. PSH: Laparoscopic appendectomy (12/08/2015).
• Current meds: sertraline (Zoloft®) 50 mg PO daily, levothyroxine (Synthroid®) 75 mcg PO daily, salbutamol (albuterol, ProAir® HFA) 90 mcg/actuation INH 2 puffs q4h PRN SOB, magnesium glycinate 400 mg PO QHS.
• Social Hx: Lives in Chicago, IL with husband and 4 yo daughter. Works full-time as an accountant. Denies tobacco or illicit drug use. EtOH: 1-2 glasses of wine on weekends. Caffeine: 2 cups of coffee daily before 10:00.
• Allergies: Penicillin (urticaria).

Psychiatric Review of Symptoms

• Improved sadness and crying spells; persistent mild anhedonia and low afternoon energy. Denies euphoria or impulsivity.
• Daily generalized worry regarding work deadlines and family health; occasional restlessness. Denies panic attacks, agoraphobia, or OCD sx.
• Denies auditory/visual hallucinations, paranoia, or delusions.
• Mild difficulty with sustained concentration at work; intact memory.
• Initial insomnia (takes 60-90 mins to fall asleep); sleeps 6 hrs/night without middle-of-the-night awakenings.
• Appetite normalized over past 2 weeks; weight stable at 64.5 kg.
• Denies passive death wish, SI, HI, or self-harm behaviors.

Mental Status Exam

• Well-groomed, dressed appropriately, cooperative, good eye contact, no psychomotor agitation or retardation.
• Normal rate, rhythm, volume, and prosody.
• Mood described as "a bit better, still stressed"; affect is dysthymic and mildly anxious, congruent with mood, full range.
• Linear, logical, and goal-directed. No flight of ideas or loosening of associations.
• Denies SI/HI. No delusions, phobias, or obsessions elicited.
• No hallucinations or illusions; appears to respond only to internal/external stimuli appropriately.
• Alert and oriented x4 (person, place, time, situation). Attention and recent/remote memory intact on conversation.
• Insight into illness and need for tx is good; judgment is intact.

Treatment Plan

Medication Changes

• Increase sertraline (Zoloft®) from 50 mg to 100 mg PO daily for ongoing MDD/GAD sx. Continue levothyroxine 75 mcg PO daily and salbutamol PRN.

Psychotherapy

• Referred to in-network LCSW for weekly CBT focusing on anxiety management and cognitive restructuring.

Patient Education

• Discussed expected timeline for dose titration (2-4 weeks for full effect) and potential SEs (GI upset, activation, insomnia). Reviewed sleep hygiene protocols, including limiting screen time 1 hr prior to bed. Provided crisis resources (988 Suicide & Crisis Lifeline) and ER return precautions for worsening depression or emergence of SI.

Follow-Up

• RTC in 4 weeks (around 12/04/2025) for med recheck and repeat PHQ-9/GAD-7. Call clinic sooner if SEs occur or sx worsen.