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SA
Sarah Albrecht
DOB 1990-03-12 · Age 34 · Aetna
Diagnoses
GAD, MDD
Provider
Dr. Lena Marsh
Last seen
2026-04-08
Next appt
10:00 AM
Balance
$0 clear
Clinical documentation
Latest signed SOAP note
subjective
Patient reports improvement in sleep over the past week following medication adjustment. Still experiencing morning anxiety "about a 5/10." Social engagement has increased—attended one family dinner. Denies SI/HI.
objective
Alert, cooperative, good eye contact. Speech normal rate/rhythm. Mood: "better than last week." Affect appropriate and somewhat brighter. Thought process linear, goal-directed. No perceptual disturbances noted.
assessment
GAD with moderate residual anxiety; MDD in partial remission. Response to escitalopram 20mg appears positive at 6-week mark. Sleep normalization is a positive indicator.
plan
Continue escitalopram 20mg QD. Reinforce behavioral activation. Schedule CBT homework review. Labs: TSH, CMP at next visit. F/U in 4 weeks or sooner PRN.