Docs/James.txt

Patient name: James
Last visit: 21/04/2023 at 16:00.

Subjective: James is a 28-year-old male who presents with a chief complaint of migraines. He reports that he has been having migraines for the past two to three months, and they usually start around 9am and get worse until noon. He states that the migraines are worse when he has a sugary breakfast or drinks a lot of soda. He also reports that the migraines can affect his vision, causing sparkles that occlude his vision.
Objective: James is an alert and oriented male in no acute distress. His vital signs are within normal limits. He has no physical signs of distress.
Assessment: Migraines
Plan: Prescribe ibuprofen to be taken daily. If symptoms persist, return in two weeks for sumatriptan.

James i a quiet and calm patient came to our clinic first time in January 2020.Subjective: James is a 28-year-old male who presents with a chief complaint of migraines. He reports that he has been having migraines for the past two to three months, and they usually start around 9am and get worse until noon. He states that the migraines are worse when he has a sugary breakfast or drinks a lot of soda. He also reports that the migraines can affect his vision, causing sparkles that occlude his vision.
Objective: James is an alert and oriented male in no acute distress. His vital signs are within normal limits. He has no physical signs of distress.
Assessment: Migraines
Plan: Prescribe ibuprofen to be taken daily. If symptoms persist, return in two weeks for sumatriptan.

Regarding travel by plane, James can travel by plane as long as he takes the prescribed ibuprofen daily and follows up with his doctor if symptoms persist.

Subjective: James reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling fatigued and has been having difficulty sleeping. He reports that he has been feeling hopeless and has been having thoughts of self-harm.
Objective: James appears to be in a depressed mood. His speech is slow and his body posture is slumped. He has poor eye contact and his attitude is apathetic. He is fully orientated and his language skills are intact.
Assessment: James appears to be suffering from major depressive disorder. His symptoms are severe and interfere with his day-to-day functioning.
Plan: 1. Meet with James again in 2 days, Friday, 20th May
2. James to follow his safety plan if required
3. James to make his family aware of his current state of mind
4. Referral to a mental health professional for further assessment and treatment
5. Monitor James' progress and adjust treatment plan as needed.

Subjective: James reports feeling down, struggling to concentrate, fatigued, difficulty sleeping, hopeless, and having thoughts of self-harm.
Objective: James appears to be in a depressed mood with slow speech, slumped body posture, poor eye contact, and an apathetic attitude. He is fully orientated and his language skills are intact.
Assessment: James appears to be suffering from major depressive disorder with severe symptoms that interfere with his day-to-day functioning.
Plan: 1. Meet with James again in 2 days, Friday, 20th May. 2. James to follow his safety plan if required. 3. James to make his family aware of his current state of mind. 4. Referral to a mental health professional for further assessment and treatment.

Subjective: James reports feeling down, struggling to concentrate, fatigued, difficulty sleeping, hopeless, and having thoughts of self-harm.
Objective: James appears to be in a depressed mood with slow speech, slumped body posture, poor eye contact, and an apathetic attitude. He is fully orientated and his language skills are intact.
Assessment: James appears to be suffering from major depressive disorder with severe symptoms that interfere with his day-to-day functioning.
Plan: 1. Meet with James again in 2 days, Friday, 20th May; 2. James to follow his safety plan if required; 3. James to make his family aware of his current state of mind; 4. Referral to a mental health professional for further assessment and treatment.