Influenza due to unidentified influenza virus with other respiratory manifestations Suicidal ideations Post-traumatic stress disorder unspecified Borderline personality disorder Dermatitis unspecified Major depressive disorder single episode unspecified Unspecified mood [affective] disorder
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
SI
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
The patient is a ___ y/o F with PMHx of complex PTSD,
borderline PD, endorses anxiety and depression, with multiple
psych admissions and prior SA, who initially presented to the ED
on ___ after making statements to friends concerning for
suicidal ideation, now found to have flu.

According to ED notes on initial presentation: "She was looking
for razors, stating she wanted to cut herself, and she did want
to cut herself but did not want to kill herself. She denies
SI/HI/AVH. She reports that in therapy this week she started
remembering previous trauma that she had not previously
remembered. Today this all came "flooding" back, and it set off
this episode today. She states she had one drink today, denies
any more alcohol use and denies drug use."

During her initial ED stay, she was diagnosed with flu and was
started on Tamiflu. She was also placed on Macrobid for possible
UTI. She was ultimately placed in an inpatient psych unit.
However, when she arrived there, she was sent back to the ED
given + flu.

ED Course:
Initial VS: 97.9 79 96/69 12 99% RA 
No new labs during most recent ED stay. Labs during initial ED
stay notable for negative serum and urine tox screens. UA with 
11
WBCs and few bacteria. Flu B positive.
Meds given:
___ 02:08 PO Acetaminophen 1000 mg  
___ 02:08 PO Ibuprofen 600 mg  
___ 08:12 PO/NG OSELTAMivir 75 mg  
___ 08:12 PO Nitrofurantoin Monohyd (MacroBID) 100 mg 
___ 16:14 PO Acetaminophen 1000 mg   
___ 16:14 PO Ibuprofen 600 mg  
___ 19:52 PO/NG OSELTAMivir 75 mg  
___ 19:52 PO Nitrofurantoin Monohyd (MacroBID) 100 mg 
___ 07:41 PO/NG OSELTAMivir 75 mg   
___ 07:41 PO Nitrofurantoin Monohyd (MacroBID) 100 mg 
___ 10:45 PO Acetaminophen 1000 mg  
___ 20:06 PO/NG OSELTAMivir 75 mg   
___ 20:06 PO Nitrofurantoin Monohyd (MacroBID) 100 mg 

VS prior to transfer: 97.7 78 99/60 16 98% RA 

On arrival to the floor, the patient endorses the above story.

Regarding her psychiatric symptoms, she denies having any true
SI. She states that the told her friends that she wanted to cut
herself but not kill herself. She feels that some statements she
had made in the past were mistaken as statements made on the day
of presentation. She reports that her mood is "good." She denies
any current SI, anxiety.

Otherwise, she endorses fevers, myalgias, cough (productive of
clear sputum), headache that began the day prior to her ED
presentation. Her roommate was recently sick with the flu. The
patient reports that her symptoms have largely resolved at this
time, with only mild lingering aches and headache. Her last 
fever
appears to have been on the evening of ___ in the ED (101.6).
Regarding potential UTI, the patient reports that the only
urinary symptom she has had is dark urine. She denies any 
dysuria
or urinary frequency.

 
Past Medical History:
Pt denies PHMx to me.
Per psych note:
-complex PTSD, borderline PD; patient also endorses anxiety and
depression 
-Hospitalizations: Multiple, at least 4- ___ in ___
in ___ after attempting to hang herself. ___ @ ___ after
___ by suffocation. ___ ___. ___ ___. 
-Psychiatrist: denies having one, reports she is waiting for one
at ___, previously seeing Dr. ___ @ ___ 
-Therapist: ___ ___ and ECT trials: sertraline, fluoxetine, clonidine,
prazosin
-Self-injury/Suicide attempts: history of cutting and burning
since age ___. Multiple SAs by hanging, overdosing, drowning
-Harm to others: denies
-Trauma: history of emotional and physical abuse from father
while growing up.
 
Social History:
___
Family History:
Significant for cancer and psychiatric illness. Pt unaware of
further details.
 
Physical Exam:
ADMISSION EXAM:

VS - ___ 0230 Temp: 99.5 PO BP: 109/67 HR: 83 RR: 16 O2 
sat:
97% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ 
GEN - Alert, NAD
HEENT - NC/AT, MMM
NECK - Supple
CV - RRR, no m/r/g
RESP - Breathing appears comfortable, no w/r/r appreciated
ABD - S/NT/ND, BS present
EXT - No ___ edema or calf tenderness
SKIN - No apparent rashes
NEURO - MAE
PSYCH - Flat affect

DISCHARGE EXAM:

Afebrile in the AM, with SBP 94. Lungs clear with normal 
symmetric chest rise.
 
Pertinent Results:
LABORATORY RESULTS:

___ 02:30AM BLOOD WBC-6.0 RBC-4.15 Hgb-12.1 Hct-36.5 MCV-88 
MCH-29.2 MCHC-33.2 RDW-13.4 RDWSD-43.2 Plt ___
___ 02:30AM BLOOD Neuts-64.8 Lymphs-12.3* Monos-20.2* 
Eos-1.5 Baso-0.5 Im ___ AbsNeut-3.86 AbsLymp-0.73* 
AbsMono-1.20* AbsEos-0.09 AbsBaso-0.03
___ 02:30AM BLOOD Plt ___
___ 02:30AM BLOOD Glucose-112* UreaN-9 Creat-0.8 Na-138 
K-3.8 Cl-103 HCO3-24 AnGap-11
___ 02:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG 
Tricycl-NEG
 
Brief Hospital Course:
On admission, the patient's influenza symptoms had resolved. She 
will need to finish one additional day of oseltamavir, and 
otherwise has no contraindication to returning to her dorm. 

She was followed up by our psychiatry team. I am quoting their 
recommendations here:  

- PTSD
- Borderline personality d/o
- Chronic: eczema

Complex case of young ___ freshman with trauma hx, recently
admitted to ___, brought to ED after making further 
statements
about killing herself to her roommate, c/w dissociative
state based on information in OMR and from therapist. Patient 
has
benefited from the contained environment in the ED and has not
been suicidal or had any dissociative episodes since ___. Risk
assessment complex; certainly remains at chronic elevated risk
given both family hx of suicide attempts and personal hx of
suicide attempts, but insight/judgment have been improving
steadily, and she is engaged in treatment planning. At this 
point
appears at low acute risk of harm to self; hopeful, forward
looking, caring for self here throughout stay, motivated for
school and keeping up grades, has not been cutting, agreeable to
more intensive supports. Cannot r/o some sort of ongoing trauma
in community, although patient adamantly denies, given continued
dissociative events with no obvious trigger (usually triggers
have been impending contact with family); outpatient therapist
continuing to work with patient on this. Unfortunately, 
inpatient
psychiatric admission continues to present elevated risk of
regression in that more intensive setting. In terms of 
treatment,
given patient not willing to consider additional medications at
this time, I don't think an inpatient unit would be useful; she
would benefit more from additional outpatient supports eg The
Trauma Center in ___ (therapist will refer for DBT). She 
is
also wlling to consider an IOP. Both would be most likely way to
decrease her long term risk.  

RECOMMEND:
- No psychiatric contraindication to d/c
- ED social worker working on referral to IOP (she will call
patient with appointment if obtained after pt is discharged)
- Re:entry meeting today at 11 am ___, ___
- Pt should f/u with her therapist ___
- Patient should return to the ED if any thoughts of self-harm 
or
any further dissociative episodes
- Therapist making referral for psychiatry through her clinic 
and
will also likely refer to additional trauma based resources
- ___ requesting call from medicine if patient is
going to be discharged to discuss flu precautions needed for 
dorm
if any ___

After discussion with ___ health, she was discharged back 
to ___ health. 

> 30 minutes spent on complex discharge.

 
Discharge Medications:
1.  OSELTAMivir 75 mg PO BID Duration: 5 Days 
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*2 
Capsule Refills:*0 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Influenza
Suicidal ideation

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

 
Discharge Instructions:
You were admitted to the medical ward with influenza. You 
received four days of Tamiflu; you will need to finish one final 
day. You were closely followed by our psychiatry team, and you 
will transfer back to BU to continue your care there.
 
Followup Instructions:
___

{'fevers': ['Influenza due to unidentified influenza virus with other respiratory manifestations'], 'myalgias': ['Influenza due to unidentified influenza virus with other respiratory manifestations'], 'cough': ['Influenza due to unidentified influenza virus with other respiratory manifestations'], 'headache': ['Influenza due to unidentified influenza virus with other respiratory manifestations'], 'anxiety': ['Suicidal ideations', 'Post-traumatic stress disorder', 'Borderline personality disorder'], 'depression': ['Suicidal ideations', 'Post-traumatic stress disorder', 'Borderline personality disorder'], 'self-injury': ['Suicidal ideations', 'Post-traumatic stress disorder', 'Borderline personality disorder'], 'suicidal ideation': ['Suicidal ideations', 'Post-traumatic stress disorder', 'Borderline personality disorder']}