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Subjective: Jerry Tylor is a 56-year-old male who presented to the emergency department with sudden onset of severe chest pain. He has a history of hypertension and type 2 diabetes, and is taking metformin 1000 mg twice daily and lisinopril 20 mg once daily. | |
Objective: Jerry appears to be in pain and is exhibiting signs of distress. His vital signs are as follows: blood pressure of 140/90 mmHg, heart rate of 90 bpm, respiratory rate of 18 breaths per minute, and oxygen saturation of 98%. | |
Assessment: Jerry is exhibiting signs of chest pain and is in need of further assessment and treatment. | |
Plan: 1. Administer oxygen and monitor vital signs. | |
2. Obtain an electrocardiogram (ECG) and chest X-ray. | |
3. Administer pain medication as needed. | |
4. Refer Jerry to a cardiologist for further assessment and treatment. | |
Subjective: Jerry Taylor is a 25-year-old male who reports feeling "down and out" for the past few weeks. He states that he has been having difficulty sleeping, and that he has been feeling more irritable and anxious than usual. He reports that he has been having difficulty concentrating and that he has been feeling more fatigued than usual. He also reports feeling hopeless and helpless, and that he has been having thoughts of suicide. | |
Objective: Jerry appears to be in a depressed mood. He has poor eye contact and his speech is slow and monotone. He is oriented to person, place, and time. He denies any hallucinations, delusions, or other psychotic-related symptomatology. | |
Assessment: Jerry appears to be suffering from major depressive disorder. His symptoms are severe and interfere with his day-to-day functioning. | |
Plan: Refer Jerry to a mental health professional for further evaluation and treatment. Provide Jerry with resources and support to help him cope with his depression. Monitor Jerry's progress and provide ongoing support. | |
Subjective: Jerry Taylor is a 25-year-old male who reports feeling "down and out" for the past few weeks. He states that he has been having difficulty sleeping, and that he has been feeling more irritable and anxious than usual. He reports that he has been having difficulty concentrating and that he has been feeling more fatigued than usual. He also reports feeling hopeless and helpless, and that he has been having thoughts of suicide. | |
Objective: Jerry appears to be in a depressed mood. He has poor eye contact and his speech is slow and monotone. He is oriented to person, place, and time. He denies any hallucinations, delusions, or other psychotic-related symptomatology. | |
Assessment: Jerry appears to be suffering from major depressive disorder. His symptoms are severe and interfere with his day-to-day functioning. | |
Plan: Refer Jerry to a mental health professional for further evaluation and treatment. Provide Jerry with resources and support to help him cope with his depression. Monitor Jerry's progress and provide ongoing support. | |
Subjective: Jerry Taylor is a 25-year-old male who reports feeling "down and out" for the past few weeks. He states that he has been having difficulty sleeping, and that he has been feeling more irritable and anxious than usual. He reports that he has been having difficulty concentrating and that he has been feeling more fatigued than usual. He also reports feeling hopeless and helpless, and that he has been having thoughts of suicide. | |
Objective: Jerry appears to be in a depressed mood. He has poor eye contact and his speech is slow and monotone. He is oriented to person, place, and time. He denies any hallucinations, delusions, or other psychotic-related symptomatology. | |
Assessment: Jerry appears to be suffering from major depressive disorder. His symptoms are severe and interfere with his day-to-day functioning. | |
Plan: 1. Refer Jerry to a mental health professional for further evaluation and treatment. 2. Provide Jerry with resources and support to help him cope with his depression. 3. Monitor Jerry's progress and provide ongoing support. | |
Subjective: Jerry Taylor is a 25-year-old male who reports feeling "down and out" for the past few weeks. He states that he has been having difficulty sleeping, and that he has been feeling more irritable and anxious than usual. He reports that he has been having difficulty concentrating and that he has been feeling more fatigued than usual. He also reports feeling hopeless and helpless, and that he has been having thoughts of suicide. | |
Objective: Jerry appears to be in a depressed mood. He has poor eye contact and his speech is slow and monotone. He is oriented to person, place, and time. He denies any hallucinations, delusions, or other psychotic-related symptomatology. | |
Assessment: Jerry appears to be suffering from major depressive disorder. His symptoms are severe and interfere with his day-to-day functioning. | |
Plan: A comprehensive treatment plan should be developed to address Jerry's symptoms. This should include psychotherapy, medication management, and lifestyle modifications. Referrals to other mental health professionals and support groups should also be considered. | |
Subjective: Jerry Taylor is a 25-year-old male who reports feeling "down and out" for the past few weeks. He states that he has been having difficulty sleeping, and that he has been feeling more irritable and anxious than usual. He reports that he has been having difficulty concentrating and that he has been feeling more fatigued than usual. He also reports feeling hopeless and helpless, and that he has been having thoughts of suicide. | |
Objective: Jerry appears to be in a depressed mood. He has poor eye contact and his speech is slow and monotone. He is oriented to person, place, and time. He denies any hallucinations, delusions, or other psychotic-related symptomatology. | |
Assessment: Jerry appears to be suffering from major depressive disorder. His symptoms are severe and interfere with his day-to-day functioning. | |
Plan: A comprehensive treatment plan should be developed to address Jerry's symptoms. This should include psychotherapy, medication management, and lifestyle modifications. Referrals to other mental health professionals and support groups should also be considered. | |