Patient Name: Charlos Doctor Name: John Subjective: Charlos reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling more irritable than usual and has been having difficulty sleeping. He reports that he has been feeling more anxious than usual and has been having difficulty focusing on tasks. Objective: Charlos appears to be listless, distracted, and minimally communicative. His speech is normal in rate, volume, and articulation and is coherent and spontaneous. His language skills are intact. There are signs of severe depression, including body posture, eye contact, and attitude. The slowness of physical movement helps reveal depressive symptomatology. There are no apparent signs of hallucinations, delusions, or any other indicators of psychotic processes. Associations are intact, and thinking is logical. He appears to have good insight. The thought process seems to be intact, and Charlos is fully orientated. Assessment: Charlos presents with symptoms of major depressive disorder, which interfere with his day-to-day functioning and require ongoing treatment and support. Plan: 1. Meet with Charlos again in 2 days, Friday, 20th May 2. Refer Charlos to a mental health professional for further assessment and treatment Subjective: Charlos reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling more irritable than usual and has been having difficulty sleeping. He reports that he has been feeling more anxious than usual and has been having difficulty focusing on tasks. Objective: Charlos appears to be listless, distracted, and minimally communicative. His speech is normal in rate, volume, and articulation and is coherent and spontaneous. His language skills are intact. There are signs of severe depression, including body posture, eye contact, and attitude. The slowness of physical movement helps reveal depressive symptomatology. There are no apparent signs of hallucinations, delusions, or any other indicators of psychotic processes. Associations are intact, and thinking is logical. He appears to have good insight. The thought process seems to be intact, and Charlos is fully orientated. Assessment: Charlos presents with symptoms of major depressive disorder, which interfere with his day-to-day functioning and require ongoing treatment and support. Plan: 1. Meet with Charlos again in 2 days, Friday, 20th May 2. Refer Charlos to a mental health professional for further assessment and treatment Subjective: Charlos reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling more irritable than usual and has been having difficulty sleeping. He reports that he has been feeling more anxious than usual and has been having difficulty focusing on tasks. Objective: Charlos appears to be listless, distracted, and minimally communicative. His speech is normal in rate, volume, and articulation and is coherent and spontaneous. His language skills are intact. There are signs of severe depression, including body posture, eye contact, and attitude. The slowness of physical movement helps reveal depressive symptomatology. There are no apparent signs of hallucinations, delusions, or any other indicators of psychotic processes. Associations are intact, and thinking is logical. He appears to have good insight. The thought process seems to be intact, and Charlos is fully orientated. Assessment: Charlos presents with symptoms of major depressive disorder, which interfere with his day-to-day functioning and require ongoing treatment and support. Plan: 1. Meet with Charlos again in 2 days, Friday, 20th May 2. Refer Charlos to a mental health professional for further assessment and treatment Subjective: Charlos reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling more irritable than usual and has been having difficulty sleeping. He reports that he has been feeling more anxious than usual and has been having difficulty focusing on tasks. Objective: Charlos appears to be listless, distracted, and minimally communicative. His speech is normal in rate, volume, and articulation and is coherent and spontaneous. His language skills are intact. There are signs of severe depression, including body posture, eye contact, and attitude. The slowness of physical movement helps reveal depressive symptomatology. There are no apparent signs of hallucinations, delusions, or any other indicators of psychotic processes. Associations are intact, and thinking is logical. He appears to have good insight. The thought process seems to be intact, and Charlos is fully orientated. Assessment: Charlos presents with symptoms of major depressive disorder, which interfere with his day-to-day functioning and require ongoing treatment and support. Plan: 1. Meet with Charlos again in 2 days, Friday, 20th May 2. Refer Charlos to a mental health professional for further assessment and treatment Subjective: Charlos reports that he has been feeling down and has been struggling to concentrate. He states that he has been feeling more irritable than usual and has been having difficulty sleeping. He reports that he has been feeling more anxious than usual and has been having difficulty focusing on tasks. Objective: Charlos appears to be listless, distracted, and minimally communicative. His speech is normal in rate, volume, and articulation and is coherent and spontaneous. His language skills are intact. There are signs of severe depression, including body posture, eye contact, and attitude. The slowness of physical movement helps reveal depressive symptomatology. There are no apparent signs of hallucinations, delusions, or any other indicators of psychotic processes. Associations are intact, and thinking is logical. He appears to have good insight. The thought process seems to be intact, and Charlos is fully orientated. Assessment: Charlos presents with symptoms of major depressive disorder, which interfere with his day-to-day functioning and require ongoing treatment and support. Plan: 1. Meet with Charlos again in 2 days, Friday, 20th May 2. Refer Charlos to a mental health professional for further assessment and treatment