Depressive disorder not elsewhere classified Suicidal ideation Asymptomatic human immunodeficiency virus [HIV] infection status Cocaine abuse unspecified Alcohol abuse unspecified
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: PSYCHIATRY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
"depression and thoughts of suicide"
 
Major Surgical or Invasive Procedure:
None
 
History of Present Illness:
___ F w/ h/o HIV, head injury, polysubstance abuse/dependence
and reported depression who p/w onset of SI in the context of
alcohol and crack cocaine use. Pt reports that she has been
feeling "depressed" for "a few days." She describes poor sleep
(none over the past night), low energy, decreased appetite, poor
self care (not showering, dressing), and anhedonia ("I don't 
want
to do anything"). Acknowledges that drinking "a couple of beers"
and smoking crack yesterday worsened her mood. She reports onset
of SI overnight that she describes and "just not wanting to live
anymore." She denies any plan, but states, "I don't trust myself
right now" and "I have nothing to do except contemplate 
suicide."
She is unable to identify any acute or chronic stressors. Asked
what she would think would be most helpful, she replies, "I
probably would rather be hospitalized...Before, it helped." She
reports that she does not currently have any outpatient mental
health providers.

On psychiatric review of systems, pt endorses AH (intermittent
"voices...mutters"- alleviated by Elavil, no a/w substance use),
panic attacks (characterized by SOB, palpitations, tremor,
diaphoresis, anxiety), and paranoia (intermittent; unable to
further describe). She denies current or past decreased need for
sleep, IOR, TI/TB, HI, impairment of concentration/memory.
 
Past Medical History:
HIV (dx ___
h/o Head injury (___) - pt reports she was "assaulted" and
subsequently received 300 stitches, was hospitalized x 2wks, and
underwent rehab at ___ she denies LOC or persistent
deficits but receives SSDI for this injury

PSYCHIATRIC HISTORY:
Dx/Sxs- Per pt, depression, panic attacks, polysubstance (ETOH,
crack, heroin) abuse/dependence.
Hospitalizations- Per pt, multiple hospitalizations at ___
(last, ___ and ___ (last, 5+ yrs ago). Per OMR, multiple
(>20) detox admissions. No record of treatment at ___ in
Partners system.
SA/SIB- Per pt, OD on Ultram "probably to hurt [her]self" ___
ago)
Psychiatrist- None
Therapist- None
Medication Trials- Elavil

SUBSTANCE ABUSE HISTORY:
ETOH- reports current use < 1/month; reports "a couple of beers"
yesterday, last drink at noon; h/o dependence; denies h/o
withdrawal seizures or DTs, but has required inpatient detox.
Cocaine- reports current use < 1/month; h/o dependence
Opiates- h/o IV heroin use; reports last use ___ ago (per OMR
note in ___, she endorsed using heroin at that time)
Tobacco- ___
Denies use of all other illicit or prescription drugs.
 
Social History:
___
Family History:
Denies h/o psychiatric illness, suicide attempts, addictions.
 
Physical Exam:
*VS:  BP: 118/79  HR: 86  temp: 98.3   resp: 16 O2 sat: 
98%height: 62"  weight: 136 lbs.
  Neurological:
    *station and gait: steady and non-ataxic
    *tone and strength: full strength
    cranial nerves: II-XII intact
    abnormal movements: no adventitious movements or tremors
  *Appearance: thin woman, hair pulled back, appears clean in
hospital gown
  Behavior: appropriate, calm, irritable and superficially
cooperative
  *Mood and Affect: "depressed", affect somewhat constricted and
dysthymic
  *Thought process: linear, logical, without loose associations
  *Thought Content: no evidence for delusions or hallucinations
     SI/HI: Endorses ongoing SI without plan, no HI
  *Judgment and Insight: both generally limited
  Cognition:
    *Attention, *orientation, and executive function: alert,
oriented, to person, place, time
    *Memory: recall intact
    *Fund of knowledge: appropriate
    Calculations: not tested
    Abstraction: not tested
    Visuospatial: not tested
    *Speech: appropriate rate, rhythm, tone
    *Language: appropriate vocabulary for context

  Gen: Thin well-developed female appearing stated age
  HEENT: NCAT, MMM, PERRL,
  CV: RRR no murmur
  Resp: CTAB
  ___: NT/ND
  Neuro: MAEW, CNII-XII intact, gait stable and non ataxic
  Skin: no rashes or excoriations
  Heme: no hemorrhage or bruising
 
Pertinent Results:
___ 05:40AM   WBC-4.3 RBC-3.87* HGB-10.8* HCT-33.8* MCV-87 
MCH-27.9 MCHC-32.0 RDW-16.7*
___ 05:40AM   NEUTS-58.7 ___ MONOS-2.9 EOS-0.2 
BASOS-0.4
___ 05:40AM   PLT COUNT-313

___ 05:40AM   GLUCOSE-107* UREA N-16 CREAT-0.6 SODIUM-138 
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-21* ANION GAP-18
___ 05:40AM   ALT(SGPT)-40 AST(SGOT)-49* CK(CPK)-216* ALK 
PHOS-80 TOT BILI-0.2
___ 05:40AM   CALCIUM-9.0 PHOSPHATE-5.0* MAGNESIUM-1.9

___ 05:40AM   cTropnT-<0.01

___ 05:40AM   TSH-0.90

___ 03:30PM   VIT B12-406 FOLATE-15.9

___ 03:30PM   HCG-<5

___ 05:40AM   ASA-NEG ETHANOL-66* ACETMNPHN-NEG 
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:40AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG 
cocaine-POS amphetmn-NEG mthdone-NEG
 
Brief Hospital Course:
___ F w/ h/o HIV, head injury, polysubstance abuse/dependence 
and reported depression admitted ___ following onset of SI in 
the context of alcohol and crack cocaine use. 

# Depression: Patient unable to identify stressors but notes 
that she had stopped attending support groups at ___ prior to 
admission. Also appears to have some degree of housing 
instability, given "housing court" appearance scheduled for ___. 
It is unclear how h/o head injury might affect her current 
presentation or perception of it. Attempts to obtain collateral 
from PCP ___ infectious disease specialist) regarding 
depression and substance abuse were unsuccessful, but messages 
were left to alert provider of ___ admission. Patient 
declined consent to contact any social supports, including 
family members. 

Patient was continued on home amitriptyline. Given previous 
positive response to sertraline, this was restarted at 25mg and 
tolerated well. Patient reported improvement in depressed mood, 
low energy and sleep over the course of admission. SI resolved. 
Patient felt that poor sleep was likely the trigger for relapse 
of depression and discussed ways to support good sleep and 
intervene sooner if she begins to have sleep difficulties. 
Patient reported no current or previous outpatient mental health 
providers and requested referrals. 

Patient remained in good behavioral control on the unit and was 
appropriate in interactions with staff and other patients. She 
participated in some groups but was observed to frequently be 
isolated to her room.

# Substance abuse/dependence: Patient reports a history of heavy 
alcohol and crack cocaine use for which she has undergone 
multiple detoxes. However, she reports only occasional use in 
recent months/years. While acknowledging that both substances 
worsened her mood, she denied any other withdrawal symptoms and 
did not require detox on this admission. 

# HIV: CD4 282 on admission. Followed at ___ by ID specialist 
Dr. ___.  Continued on home darunavir (Prezista), 
ritonavir (Norvir), Truvada. Patient required considerable 
education and reassurance surrounding naming of her HIV meds, as 
she refused them initially because she did not recognize the 
generic names.

# Safety: No acute safety concerns. Maintained on Q15min checks.

# Legal: ___
Medications on Admission:
(Medication confirmed with Dr. ___ MD ___ Dr. 
___
     Amytriptiline 50 mg PO qhs
     Truvada 200-300 1 tab PO daily
     Prezista 600 1 tab PO BID
     Norvir 100 PO daily
     *Additionally patient reports taking Vicodin 750 TID but 
covering physician denied this
 
___ Disposition:
Home
 
Discharge Diagnosis:
Depressive disorder Not-Otherwise-Specified (Considerations 
include Major depressive disorder and Substance-induced mood 
disorder)
HIV
h/o Head injury

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

VSS
MSE: Mood 'alright', denies SI/HI, feels ok for d/c home, TC 
WNL, TP linear, logical, speech WNL

 
Discharge Instructions:
-Please follow up with all outpatient appointments as listed - 
take this discharge paperwork to your appointments.
-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether 
prescription drugs or illegal drugs--as this can further worsen 
your medical and psychiatric illnesses.
-Please contact your outpatient psychiatrist or other providers 
if you have any concerns.
-Please call ___ or go to your nearest emergency room if you 
feel unsafe in any way and are unable to immediately reach your 
health care providers.

*It was a pleasure to have worked with you, and we wish you the 
best of health.*
 
Followup Instructions:
___

{'depression': ['Depressive disorder', 'not elsewhere classified'], 'thoughts of suicide': ['Suicidal ideation'], 'HIV': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'polysubstance abuse/dependence': ['Cocaine abuse', 'unspecified', 'Alcohol abuse', 'unspecified'], 'head injury': [], 'poor sleep': [], 'low energy': [], 'decreased appetite': [], 'poor self care': [], 'anhedonia': [], 'panic attacks': [], 'paranoia': [], 'intermittent voices': [], 'substance-induced mood disorder': []}