20 Feb Focused SOAP Note

Patient: White female, late 40s History: Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD) Current Medications: Sertraline (Zoloft), self‑reduced dose recently; now titrating back to prior level Provider: New primary care provider in Maryland

Subjective
Chief Complaint: “My mood and anxiety have worsened since I reduced my medication.”

History of Present Illness:

Reports daily low mood, irritability, avoidance behaviors, and low energy.

Moderate anxiety episodes weekly; rare severe panic‑like episodes (4 lifetime, last in Sept. previous year) with uncontrollable shaking, rigidity, vomiting, and speech difficulty.

Symptoms worsened after self‑reducing sertraline due to running out of medication during relocation.

Recently re‑established care and is motivated to restart treatment.

Psychiatric History: Diagnosed with depression and anxiety in early 20s; consistent sertraline use for 10 years. Denies mania, impulsivity, or psychotic symptoms.

Social History: Recently relocated from Georgia to Maryland; improved support system.

Family History: Not specified.

Substance Use: Not reported.

Patient’s Perspective: Attributes anxiety to chronic stress and poor coping mechanisms; expresses motivation to improve mental health.

Objective
Appearance: Alert, oriented, cooperative.

Mood/Affect: Reports depressed mood; affect congruent, mildly anxious.

Speech: Normal rate and tone; occasional hesitancy when discussing panic episodes.

Thought Process: Logical, goal‑directed.

Thought Content: No delusions, hallucinations, or suicidal ideation reported.

Behavior: Avoidance noted; otherwise appropriate.

Cognition: Intact; no gross deficits.

Insight/Judgment: Fair; recognizes impact of medication lapse and need for therapy.

Vitals/Physical Exam: Not provided; no acute distress observed.

Assessment
Primary Diagnoses:

Major Depressive Disorder, recurrent, moderate.

Generalized Anxiety Disorder.

Differential Diagnoses:

Panic Disorder (given rare severe episodes, though infrequent and atypical).

Adjustment Disorder (symptom exacerbation linked to relocation and medication lapse).

Clinical Impression:

Worsening mood and anxiety due to self‑reduction of sertraline.

Motivated to reengage in treatment; improved social support is protective.

No evidence of mania, psychosis, or substance‑related disorder.

Plan
Pharmacological Management:

Continue titration of sertraline back to therapeutic dose (per prior regimen).

Monitor for side effects and efficacy.

Consider augmentation if symptoms persist (e.g., buspirone for anxiety, bupropion for energy/motivation).

Therapy:

Initiate supportive psychotherapy.

Recommend CBT for anxiety and depressive symptoms.

Explore stress management and coping skills training.

Monitoring:

Regular follow‑up visits to assess mood, anxiety, and medication adherence.

Monitor for recurrence of severe panic‑like episodes.

Screen for suicidality at each visit.

Education:

Discuss importance of medication adherence.

Provide psychoeducation on depression and anxiety.

Encourage use of support system in Maryland.

Lifestyle/Supportive Measures:

Promote sleep hygiene, exercise, and balanced nutrition.

Encourage engagement in social activities to reduce avoidance.

Safety:

No current suicidal ideation; continue monitoring.

Provide crisis resources if symptoms escalate.

Signature/Provider: ___________________________ Date: ___________________________