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K. Lee 41 M · Psychiatric medication management · MRN 62014
Apr 21 10:14 AM
Subjective

Patient reports reduced anxiety and improved concentration on sertraline 100 mg daily. Mild gastrointestinal upset is resolving. Sleep 6–7 hours nightly; appetite stable. Denies mania, psychosis, suicidal ideation or homicidal ideation. Adherence confirmed; no substance use reported.

Mental Status Exam

Well groomed, cooperative and fully oriented. Normal speech, linear and goal-directed thought process. Mood: ‘less anxious’; affect congruent. No hallucinations or delusions. Insight and judgment intact. PHQ-9: 6; GAD-7: 8, improved from 14.

Risk Assessment

No current SI/HI, intent or plan. Protective factors include family support, treatment engagement and future orientation. Acute risk assessed as low. Crisis resources and safety plan reviewed.

AssessmentF41.1

Generalized anxiety disorder, DSM-5 300.02 / ICD-10 F41.1, improving with pharmacotherapy. Symptoms and functional impairment reviewed. Prescribing rationale and treatment response documented; E/M coding remains subject to clinician review.

Plan

Continue sertraline 100 mg daily. Discussed benefits, common adverse effects and alternatives; patient agrees. Continue psychotherapy and sleep hygiene. Monitor tolerability and GAD-7 at next visit. Follow up in 6 weeks, sooner for worsening symptoms.

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Live transcript Recording 00:00
Psychiatrist
How is sertraline working?
Patient
Less anxious. Stomach upset is settling. No thoughts of self-harm.
K. Lee 41 M · Medication management · MRN 62014
Apr 21 10:14 AM
Subjective

Mental Status Exam

Risk

Assessment

Plan

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