Mini soap notes 2
Total of 7 mini soap notes: A case study will NOT be provided; cases will be hypothetical and needs to be realistic
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Chief Complaint:” Follow-up after change in medications”
S- Presents for 4-week medication management follow up. Last seen 7/31, at which time we increased sertraline to 150 mg and continued quetiapine 50 mg HS PRN and propranolol 20 mg BID PRN. Reviewed interim history. He has been taking his medication on a regular basis and denies side effects. Anxiety and depression have improved with the increase of sertraline. PHQ-9 is 5, GAD-7 is 7 today. Also indicates improved energy and decreased anhedonia. Reports average of 8 hours of restful, restorative sleep each night with quetiapine. Propranolol remains effective for social anxiety, which he takes prior to hosting Zoom presentations at work. He is somewhat anxious about returning to work in-person, as he has been working remotely from home since the pandemic began. Endorses suicidal ideation that is fleeting and passive with no plan, drive, or intent. He has no history of self-harm and this appears to be at baseline for him. He describes having adequate support, and continues to see his long-term therapist bi-weekly. Reviewed crisis plan. Appetite is stable. No new medical concerns.
O- Vitals: BP 137/69 HR 76 RR 18 Temp 97.9
A- Major Depressive Disorder, recurrent, moderate (F33.1); Social Phobia, generalized (F40.11); Insomnia due to other mental disorder (F51.05)
P- Start Vitamin D3 50,000 IU weekly for Vitamin D deficiency. Continue sertraline 150mg daily for mood and anxiety, quetiapine 50mg HS PRN for insomnia, and propranolol 20mg BID PRN for social anxiety. Continue outpatient therapy as scheduled. Return to care in 8-12 weeks or sooner as needed.