Follow-up Psychiatric Visit SOAP [[MZ]] 28/Nov -> 5/Dec

Date & Attendees:
2026-02-06
Attendees: Jamie Lin (clinician), Casey (patient)

Reason For Visit:
Casey presents with persistent trauma-related nightmares, daytime anxiety, and decreased motivation.

Subjective:
Best Hopes:
Casey hopes to achieve improved sleep quality and reduced frequency of nightmares, which they believe will help alleviate their daytime anxiety and feelings of being overwhelmed.

Current Medications & Adherence:
Sertraline, selective serotonin reuptake inhibitor (antidepressant), 100 milligrams daily. Casey reports adherence to their current medication regimen.

History of present illness:
Since the last visit, Casey has continued to experience trauma-related nightmares almost every night. These symptoms have persisted for an extended duration and occur with nightly frequency, with a severity level described as exhausting and overwhelming. Casey reports that the nightmares have not increased in intensity. They note that the persistent nightmares contribute to significant daytime fatigue, increased anxiety, and a marked decrease in motivation. Even minor daily tasks feel overwhelming. The symptoms are primarily influenced by poor sleep quality, and Casey believes that improvement in sleep would positively impact daytime functioning. These symptoms have negatively affected daily life, including the ability to manage routine activities and maintain motivation.

Psychiatric History:
Casey has a history of trauma-related nightmares, anxiety, and decreased motivation. They are currently prescribed sertraline for these symptoms. There is no prior knowledge or use of prazosin. Casey has not reported any recent changes in psychiatric history aside from the persistence of current symptoms.

Metabolic Monitoring:
HR (sitting), BP (sitting): 
HR (standing), BP (standing): 
height: 
weight: 
Waist circumference: 
BMI: 

Rating Scales and Investigations:
PHQ-9: 
GAD-7: 
PRS (Psychosis Rating Scale): 

Objective:
Mental Status Examination: Orientation: Casey is oriented to time, place, and person.

Appearance & Behavior: Casey appears fatigued but is appropriately groomed and cooperative. No abnormal movements or psychomotor agitation observed.

Speech: Speech is normal in rate, tone, and volume.

Mood: Casey describes mood as anxious and exhausted.

Affect: Affect is congruent with stated mood, with restricted range but capacity for engagement.

Thought Process: Thought processes are logical and linear. No evidence of formal thought disorder.

Thought Content: Dominant themes include anxiety and preoccupation with sleep disturbances. Casey denies suicidal ideation.

Perception: No perceptual disturbances reported. Casey denies auditory or visual hallucinations.

Cognition: Memory and attention are grossly intact.

Insight & Judgment: Casey demonstrates good insight into symptoms and judgment regarding treatment options.

Assessment:
Casey presents with persistent trauma-related nightmares, significant sleep disturbance, daytime anxiety, and decreased motivation. Symptoms are negatively impacting daily functioning. No evidence of worsening nightmare intensity. No acute safety concerns identified.

Safety plan:
Casey denies suicidal ideation or self-harm. I advised Casey to contact the clinic if they experience any concerning symptoms, such as increased dizziness or worsening nightmares.

Plan:
Biological: 1. Continue sertraline 100 mg daily without dose adjustment at this time. 2. Initiate prazosin at a low dose to address trauma-related nightmares and improve sleep quality. Psychological: Provided psychoeducation on the importance of sleep in regulating anxiety and mood. Discussed potential consideration of bupropion in the future if motivation and energy levels remain low after sleep improves. Social-Cultural: Encouraged maintaining social connections and seeking support as needed.

Patient education:
I educated Casey on the use of prazosin for trauma-related nightmares and the importance of monitoring for side effects such as dizziness or changes in dream patterns. I discussed the potential benefits of improved sleep on daytime anxiety and motivation. I reviewed sleep hygiene strategies and encouraged Casey to maintain a consistent sleep schedule.

Follow-up:
I scheduled a follow-up appointment in two weeks. I advised Casey to contact the clinic earlier if they experience any adverse effects or worsening symptoms.