Carilion Behavioral Health · Patient portal
Visit note
Date
Today
Clinician
Dr. Osei
Visit type
Telepsychiatry follow up
Duration
23 min
118/76
BP
76
HR
Stable
weight trend
Subjective
Carmen reports mood and sleep about the same as her last visit six weeks ago. She describes managing her schedule between two jobs and her children's activities, denies any new stressors, and denies any thoughts of self harm.
Objective
Affect congruent with reported mood, speech normal rate and volume on today's video visit, no acute distress observed.
Assessment
- Adjustment disorder with anxiety, stable by self report
- No acute safety concerns identified today
Plan
- Continue sertraline 100mg daily
- Routine follow up in six weeks
- Labs ordered given reported fatigue, see results in portal