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

Date & Attendees:
2026-02-07
Attendees: Dr. Jamie Lin (psychiatrist), the patient

Reason For Visit:
The patient presents with persistent anxiety and recurrent flashbacks following a workplace accident.

Subjective:
Best Hopes:
The patient expresses a desire for relief from anxiety and flashbacks, and is open to interventions that will help restore daily functioning.

Current Medications & Adherence:
Sertraline, selective serotonin reuptake inhibitor, newly prescribed. No prior psychiatric medications reported.

History of present illness:
Since the workplace accident approximately six months ago, the patient has experienced recurrent flashbacks, anxiety, hypervigilance, and sleep disturbances. The flashbacks occur a few times per week and are described as vivid and distressing, often accompanied by difficulty breathing and impaired concentration. The patient reports feeling constantly on edge, with loud noises exacerbating symptoms. Sleep is disrupted nearly every night due to difficulty falling and staying asleep. The patient describes emotional numbness, reduced social engagement, and persistent fatigue. Pertinent negatives include: the patient was not seriously physically injured during the accident, reports no sadness, no hopelessness, and no changes in interest in activities usually enjoyed, although there is a reduction in social outings.

Psychiatric History:
The patient reports no prior psychiatric diagnoses or treatments. There is no history of depressive symptoms, hopelessness, or anhedonia. The patient denies previous episodes of similar anxiety or trauma-related symptoms prior to the workplace accident.

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: The patient is oriented to time, place, and person.

Appearance & Behavior: The patient appears appropriately groomed and dressed, cooperative throughout the interview, with no observed restlessness or abnormal movements.

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

Mood: The patient describes feeling numb and anxious.

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

Thought Process: Thought processes are logical and linear, with no evidence of formal thought disorder.

Thought Content: The patient reports intrusive memories and anxiety related to the workplace accident. There is no suicidal ideation.

Perception: The patient reports no perceptual disturbances and denies auditory or visual hallucinations.

Cognition: Memory and attention are grossly intact.

Insight & Judgment: The patient demonstrates good insight into the nature of symptoms and judgment is intact.

Assessment:
The patient exhibits symptoms consistent with post-traumatic stress disorder, including recurrent flashbacks, hyperarousal, sleep disturbance, and avoidance behaviors following a traumatic workplace accident. There is no evidence of major depressive disorder or psychosis.

Safety plan:
The patient denies suicidal ideation or self-harm. No acute safety concerns are identified at this time.

Plan:
Biological: 1. Initiate sertraline 25 mg daily, with plans to titrate as tolerated. 2. Monitor for side effects and assess efficacy at follow-up. 3. Consider prescribing hydroxyzine for acute anxiety management if clinically indicated in future visits. Psychological: Provide a referral to a therapist specializing in trauma-focused psychotherapy. Social-Cultural: Encourage gradual re-engagement in social activities to support recovery.

Patient education:
I educate the patient on the nature of post-traumatic stress disorder, the expected timeline for medication efficacy, and the importance of adherence to both pharmacological and psychological interventions. I discuss sleep hygiene and coping strategies for managing anxiety and flashbacks.

Follow-up:
Follow-up appointment scheduled in four weeks. Patient instructed to contact the clinic sooner if symptoms worsen or new concerns arise.