Major depressive affective disorder single episode unspecified Suicidal ideation Alcohol abuse unspecified Calculus of kidney Family disruption due to death of family member Anxiety state unspecified Insomnia unspecified
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: PSYCHIATRY
 
Allergies: 
Verapamil / Compazine
 
Attending: ___.
 
Chief Complaint:
"embarassed"
(Presented to ED with suicidality)
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ is a ___ with a
history of depression who presents with suicidal ideation and
plan to overdose on percocet in the setting of multiple
psychosocial stressors. 

Patient states that yesterday, she went to visit her family
cemetary site as it was the ___ year anniversary of her father's
death. Afterwards, she was sitting in her car at the train 
tracks
and a train was coming.  She considered driving up onto the
tracks.  She says everyone would think it was an "accident."
Despite these thoughts, she did not move her car forward.  She
then met her brother for lunch and a drink.  She had not been
drinking recently as she gave up EtOH for lent, but had ___
drinks.  In the evening, she knew she could not drive home
because of her intoxication, so her kids picked her up.  She
admits that she had drank too much and as a result told her kids
something that she had been hiding from them; that she had an
emotional affair with another man and that her relationship with
their father was having difficulty.  The kids reassured her. 
Then at approximately 3 in the morning, she was contemplating
taking percocets or oxycodone.  She had a bottle left over from
after a surgery.  She opened the bottle and got some water to
take the pills, but then thought that if she overdosed her kids
would find her.  She did not want to put that on her children, 
so
she called her friend ___ instead.  With ___ 
support,
she called her PCP ___ referred her to the ED.

At some point she wrote a note:
"I love the 3 of you with all of my heart - I can't stand my
failures - I don't know why my brain broke. Be happy please. I
want to move. Start over. Live differently."

She has multiple stressors in her life:
- Work: ___
- Personal: Father's death ___ years ago (refers to him as her 
best
friend). ___ affair with an older man, which her husband
found out about.  Now there is marital stress; they are in
couples counseling, and they are "staying together for the
children."  

 
Past Medical History:
PAST PSYCHIATRIC HISTORY:
Diagnoses: Depression
Hospitalizations: Denies.
Current treaters and treatment: Denies current treaters.
Previously saw ___ for ___ year, stopped in ___
(___). Was referred to a psychiatrist, but only saw him
once or twice.
Medication and ECT trials: Citalopram (___), Fluoxamine
(___)
Self-injury: Denies.
Harm to others: Denies.
Access to weapons: Denies.

PAST MEDICAL HISTORY:
PCP: Dr. ___ of pyelonephritis with left renal calculus
Bell's Palsy
History of recurrent bronchitis
Malrotated slightly atrophic right kidney
Uterine fibroids
Left ECU tenosynovitis s/p synovectomy
Denies history of seizures and head injuries.

 
Social History:
SUBSTANCE ABUSE HISTORY:
EtOH: Recently gave up EtOH for lent.  Drank ___ beverages
yesterday.  Normally drinks ___ beverages upon occassion. 
Husband may have said to drink less EtOH rarely after she said
something embarrassing. Vomited from EtOH as a teen. Denies
withdrawal symptoms.  
Tobacco: As a teenager.
MJ and cocaine: Tried once ___ years ago.
Denies other substances or misusing pills.

SOCIAL HISTORY:
___
Family History:
People have had periods of feeling a little depressed, but never
diagnosed with anything.
No familial suicide attempts.
Brother drank to much when he was younger.

 
Physical Exam:
EXAM: 
*VS: T 98.6 P 78 BP 142/76 RR 18 SpO2 100%  

Neurological:  
 *station and gait: Normal station and gait.
 *tone and strength: Normal tone. ___ strength.
 cranial nerves: Intact; facial droop not noted.
 abnormal movements: None noted. FNF intact. No tremor.

Cognition: 
 Wakefulness/alertness: Alert,
 *Attention: MOYB intact.
 *Orientation: Oriented to self, BI ED and ___.
 *Memory: ___ registration and recall. Recalls past 3 
presidents.
 *Fund of knowledge: ___ and ___ as ___ plays.
 Calculations:  7 quarters in $1.75.
 Abstraction: 
     Apples/Orange: Fruit
     Apple/Fall/Tree: "People often are a product of their
environment."
 *Speech: Regular volume, rate, tone.
 *Language: Intact. Naming of glasses, clipboard, pen.
 
Mental Status:
 *Appearance: Thin caucasian female in sweatpants and sweatshirt
sitting in bed.
 Behavior: Frequently crying, fair eye contact, no PMR/PMA.
 *Mood: "Embarrassed" "Lonely"
 Affect: Distressed and tearful. Congruent. No lability.
 *Thought process / *associations: Goal directed. At times
tangential when speaking of stressors. No loosening of
associations.
 *Thought Content: SI with plan at presentation; currently with
passive SI. Denies HI, AVH. Multiple stressors (family, work,
anniversay of father's death), concern for people's perception 
of
her changing.
 *Judgment and Insight:  Insight into her depression and that 
she
needs help.  Showed good judgement in seeking help from friend.

 
Pertinent Results:
___ 06:45AM BLOOD WBC-12.2*# RBC-4.35 Hgb-13.8# Hct-40.6 
MCV-94 MCH-31.7 MCHC-33.9 RDW-12.4 Plt ___
___ 06:45AM BLOOD Neuts-83.1* Lymphs-13.7* Monos-2.4 
Eos-0.3 Baso-0.5
___ 06:45AM BLOOD Glucose-87 UreaN-12 Creat-0.7 Na-144 
K-3.3 Cl-102 HCO3-25 AnGap-20
___ 06:45AM BLOOD TSH-0.58
___ 06:45AM BLOOD T4-8.8
___ 06:45AM BLOOD ASA-NEG Ethanol-26* Acetmnp-NEG 
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

___ 07:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG 
cocaine-NEG amphetm-NEG mthdone-NEG
 
Brief Hospital Course:
#) Psychiatric
At admission Ms ___ was found to be exceedingly dysphoric 
with overwhelming tearfulness and sense of hopelessness, and 
ambivalence around her hospitalization. On the unit she again 
endorsed the numerous depressive symptoms such as insomnia, 
decreased energy, guilt, and prior suicidality though seemed 
prone to minimizing the severity of the episode, especially 
early on. She also agreed that recent escalating alcohol use 
likely contributed to her acute change and need for 
presentation. For her apparent major depressive episode she was 
started on bupropion SR 100mg BID, which she tolerated and was 
increased to 150mg BID and continued through discharge. 
Trazodone at 25mg was also used for insomnia on a PRN basis with 
good effect. She experienced fair improvement in her mental 
status with decreased mood reactivity and tearfulness and better 
interpersonal engagement with the team later in her course. Over 
her short hospitalization she was consistently visible on the 
unit milieu and in groups with positive interactions with other 
patients. She consistently denied any further lingering suicidal 
ideations after her initial eval in the ED. Her insight into the 
severity of the episode and need for multi-faceted treatment 
also improved closer to discharge.

#) Alcohol
History suggests and the patient agrees that alcohol misuse 
likely played a role in the decompensation and presentation 
leading to this admission. She agreed that eliminating this as a 
contributing agent would be a good idea. Does likely meet 
criteria for abuse though not full dependence.

#) Medical
Her home diuretic and hormone replacement were continued and no 
particular intervention was required. She noticed a mild 
headache and question of asymmetry of the facial musculature at 
one point though neuro exam was negative and the HA resolved 
with ibuprofen.

#) Legal
Ms ___ signed in voluntarily and remained as such for the 
duration of her course.

#) Social/Dispo:
Ms ___ immediate family was involved as she wished for 
treatment and discharge planning. Husband ___ came to visit 
over weekend and again for collective meeting with the team day 
prior to d/c. She will return home and pick up care with new 
outpatient providers including, briefly, the ___ 
___ immediately after discharge.

#) Risk assessment:
Ms ___ carries a small number of chronic risk factors for 
poor outcome like self-harm or suicide, namely her limited 
insight and willingness to participate in mental health 
treatment. Acute risk factors which have been addressed include 
major depressive episode, alcohol misuse behaviors, and lack of 
outpatient treatment outreach. She remains protected by her 
education and work motivation with good future orientation, sex, 
lack of major substance dependence, lack of access to weapons, 
and dependent children. This profile suggests the outpatient 
setting will be the least restrictive sufficient environment.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiloride HCl 5 mg PO DAILY 
2. Hydrochlorothiazide 50 mg PO DAILY 
3. Necon ___ (28) *NF* (norethindrone-ethin estradiol) ___ 
mg-mcg Oral Daily 

 
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO BID 
RX *bupropion HCl [Wellbutrin SR] 150 mg 1 tablet(s) by mouth 
twice a day Disp #*30 Tablet Refills:*0
2. traZODONE 25 mg PO HS:PRN insomnia 
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime 
Disp #*15 Tablet Refills:*0
3. Amiloride HCl 5 mg PO DAILY 
4. Hydrochlorothiazide 50 mg PO DAILY 
5. Necon ___ (28) *NF* (norethindrone-ethin estradiol) ___ 
mg-mcg Oral Daily 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Axis I: Major depressive disorder 
Axis II: deferred 
Axis III: History of pyelonephritis with left renal calculus 
Bell's Palsy 
History of recurrent bronchitis 

 
Discharge Condition:
VS:  98.3  71  124/81  16  99%RA

MSE: 
Appearance: blonde woman appears stated age wearing t-shirt and
sweatpants, clean and brushed hair, some makeup, medium build 
Gait/tone: both appear normal
Behavior: generally calm and cooperative, seated comfortably in
interview room, no PMR/PMA observed, no adventitious mvmts
Speech:    grossly normal rate/tone/prosody, no
slurring/dysarthria
Mood:   'better'
Affect:  reactive though less so from ___, more euthymic
overall, remains mood- and content-congruent
Thought Process:  generally logical and goal-directed though 
some
perseveration around leaving the hospital and her rights being
removed (nonpsychotic)
Thought Content: no prominent delusions/paranoia
Perceptions: denies Auditory/Visual/Somatic hallucinations; not
appearing to respond to internal stim
Suicidality/Homicidality: denies both currently
Insight/Judgment:  both somewhat limited into the nature and
severity of her depressive symptoms and need for tx, though
appear improved from last wk
Cognitive Exam: awake and alert, oriented to place, date, 
person,
situation; memory, concentration, attention grossly intact 
during
interview but not formally tested

 
Discharge Instructions:
Dear Ms. ___, 
You were admitted to ___ because you felt unstable and 
suicidal. You improved while in the hospital. It has been a 
pleasure taking care of you. We wish you good luck in your 
recovery!

-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.
 
Followup Instructions:
___

{'suicidal ideation': ['Major depressive affective disorder', 'Suicidal ideation'], 'alcohol abuse': ['Alcohol abuse'], 'family disruption due to death of family member': ['Family disruption due to death of family member'], 'anxiety state': ['Anxiety state'], 'insomnia': ['Insomnia']}