Major depressive affective disorder recurrent episode severe without mention of psychotic behavior Suicidal ideation Asthma unspecified type unspecified Unspecified essential hypertension Migraine unspecified without mention of intractable migraine without mention of status migrainosus
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: PSYCHIATRY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
"not feeling well...I think I'm having a breakdown"
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
The patient is a ___ yo AA female, history of depressive symptoms 
brought to ___ ED by co-workers after telling her supervisor 
that she "wasn't feeling well" and "I am emotionally 
distraught." Per ED report, she feels that she cannot trust her 
friends, is unhappy, and fearful of losing her job as she was 
placed on warning last ___ when she approached her boss and 
said she was having difficulties due to depression.
.
In the ED, the patient reported that she tried to kill herself 2 
nights prior to admission by overdosing on a handful of Benadryl 
and lisinopril. She could not recall the doses or the exact 
amount. She did not seek medical treatment after the ingestion 
but said "I got sick and threw up." Per the pt, one of her 
friends came over later in the evening, she then tried to cut 
her wrist with a kitchen knife but her friends stopped her and 
took all the knives out of her apartment. 
. 
The patient reported being depressed since this ___ when she 
briefly became homeless after her landlord sold the house she 
was living in. She said she stayed with friends until she found 
her own place. More recently she has been lending money to a 
woman who she thought was her friend, putting herself
in debt. Per the patient, this friend has 2 children and 
recently became unemployed; she is also Ms. ___ first 
lesbian partner. The patient has for years considered herself 
bisexual but has not been able to reveal this to her family 
because they would find it unacceptable (they are very observant 
___).  She and this woman broke up a few 
months ago and patient said that during their relationship they 
were in love. In the ED she stated, "I'm tired of people hurting 
me for no reason people always do bad things to me. I just want 
to go away and make everything stop. I can never be happy. I'm 
just tired." The patient is very concerned that she will be 
considered "crazy." 
 
Past Medical History:
PAST PSYCHIATRIC HISTORY[INCLUDE PRIOR HOSPITALIZATIONS,
OUTPATENT TREATMENT/ECT HISTORY}
* no current treaters
* age ___ psychiatrically hospitalized after she overdoesd on 
  on pills she found in the house precip. was family conflict

PAST MEDICAL HISTORY[INCLUDE HISORY OF HEAD TRAUMA , SEIZURS OR
NEUROLOGIC ILLNESS}
* PCP ___ @ ___
* ___ NP @ ___
* HTN
* Migraine headaches
* weight loss
* Low grade CIN
 
Social History:
___
Family History:
Pat uncle with ___ and hospitalizations
Mat aunts and uncles with depression
Mother with pheochromocytoma 
 
Physical Exam:
97.8  160/111   71   18    100%RA
A/B: Appears stated age, dressed in street clothes, calm,
cooperative with interviewer, appropriate eye contact.
S: normal in volume, rate, normal prosody, goal-directed
M: "better." 
A: brighter, mood-congruent, appropriate
TP: linear, goal-oriented
TC: denies SI/HI, no A/V hallucinations 
I: fair
J: fair 
C: alert and oriented x3

 
Pertinent Results:
10.3> 14.4/41.1< 269 
___ 99
Serum Tox: negative
Utox: Negative 
TSH-0.28
Urine: BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-40 
BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-SM 
Urine: RBC->182* WBC-56* BACTERIA-NONE YEAST-NONE EPI-1

 
Brief Hospital Course:
This is a ___ female with h/o SA by overdose and subsequent 
hospitalization, and longstanding, untreated depression, 
currently admitted for SA 3 days PTA by overdose with benadryl 
and lisinopril, and preempted attempt to cut wrists with a 
kitchen knife. Given the patient's h/o SA by OD and psychiatric 
hospitalization with no follow-up care and pharmacotherapy, it 
is highly likely that the patient's current presentation is a 
reoccurrance of her pre-existing, untreated depression. 
Moreover,
her presenting symptoms of anhedonia, weight loss, psychomotor 
decline, insomnia, and feeling of guilt, are consistent with 
depression with melancholic features.

Axis I: Major depressive episode, severe, recurrent; r/o bipolar 
disorder 
Axis II: Deferred
Axis III: hypertension, asthma, migraine headaches
Axis IV: financial instability, social isolation, concerns about 
sexuality
V: 40-50 

#) Major depression with melancholic features:  On admission, 
the patient endorsed multiple neurovegetative symptoms of 
depression (anhedonia, insomnia with early morning awakenings, 
decreased interest in life, decreased motivation, fatigued, 
decreased appetite, and decreased weight) in addition to 
depressed mood. She was often tearful. She and her mother denied 
any history of mania or hypomania. She was started on Buproprion 
SR that was tapered to 150 mg BID, which she tolerated well. For 
sleep, initially tried trazodone that was tapered up to 50 mg 
qhs. Pt continued to report poor sleep, and so Trazodone was 
discontinued and Seroquel 100 mg qhs was trialed with some 
improvement.  On day of discharge patient stated she was, 
"better," noted to be future oriented with no SI/HI, but 
continued to have interrupted sleep.  Follow-up as noted below. 

#). Medical:
*Hypertension: The patient had not been taking her 
antihypertensives prior to admission. She was restarted on 
Lisinopril 20 mg daily and HCTZ 25 mg daily, but continued to be 
hypertensive with SBP= 140-170/90-100's. A medicine consultation 
was obtained, recommended increasing the lisinopril to 40 mg po 
qd in addition to the HCTZ 25 mg qd. Also recommended outpatient 
follow-up with PCP and renal for further evaluation of secondary 
causes of HTN. She will need a BMP in one week. 
- Follow-up appointment with PCP and ___ as noted below. 
- The patient was compliant attending group, milieu therapy. 

*Asthma: Stable. Patient was continued on home medication of 
fluticasone 110 mcg, 1 puff BID.

#). Legal: ___
#). Safety: The patient was monitored on Q15 minute checks 
without incident.

#). Psychosocial:  The patient received group and individual 
therapy per the unit routine. Social work was in contact with 
her mother and supervisor at work. A family meeting with the 
mother occurred on the day of discharge, treatment plan was 
reviewed.
 
Medications on Admission:
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 1 
puff(s)
inhaled twice a day use twice daily for prevention of chest
tightness
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth daily take with
lisinopril-hctz ___ to total dose of 40-25.
LISINOPRIL-HYDROCHLOROTHIAZIDE - 20 mg-25 mg Tablet - 1 
Tablet(s)
by mouth daily for blood pressure control

(Patient was not taking any of these medications on admission)
 
Discharge Medications:
1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once 
a day.
Disp:*30 Tablet(s)* Refills:*0*
3. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) 
Tablet Extended Release PO twice a day.
Disp:*60 Tablet Extended Release(s)* Refills:*0*
4. Seroquel 100 mg Tablet Sig: One (1) Tablet PO at bedtime as 
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Axis I: Major depression, recurrent, severe, without psychotic 
features, r/o bipolar disorder
Axis II: deferred
Axis III: HTN, Asthma and Migraine headaches. 
Axis IV: Severe- financial instability, social isolation, 
concerns about sexuality
V: 40 

 
Discharge Condition:
Patient ambulatory without assistance at time of discharge
Condition: improved 
97.9   140/74    91    18    99%RA
A/B: Appears stated age, dressed in street clothes, calm, 
cooperative with interviewer, appropriate eye contact.
S: normal in volume, rate, normal prosody, goal-directed
M: 'better.' 
A: brighter, mood-congruent, appropriate
TP: linear, goal and future oriented 
TC: denies SI/HI, no A/V hallucinations 
I: fair
J: fair 
C: alert and oriented x3

 
Discharge Instructions:
You were admitted to the hospital because you were severely 
depressed and had attempted suicide. You were started on an 
antidepressant called Wellbutrin.  We have arranged for you to 
see a psychiatrist and a therapist.  You should bring this 
paperwork with you to all of your appointments. 
 
Followup Instructions:
___

{'not feeling well': ['Major depressive affective disorder'], "I think I'm having a breakdown": ['Major depressive affective disorder'], 'cannot trust friends': ['Major depressive affective disorder'], 'unhappy': ['Major depressive affective disorder'], 'fearful of losing job': ['Major depressive affective disorder'], 'depressed since ___': ['Major depressive affective disorder'], 'briefly became homeless': ['Major depressive affective disorder'], 'lending money to a woman': ['Major depressive affective disorder'], 'in debt': ['Major depressive affective disorder'], 'lesbian partner': ['Major depressive affective disorder'], 'tired of people hurting me': ['Major depressive affective disorder'], 'want to go away and make everything stop': ['Major depressive affective disorder'], 'can never be happy': ['Major depressive affective disorder'], 'just tired': ['Major depressive affective disorder'], "concerned that she will be considered 'crazy'": ['Major depressive affective disorder'], 'overdosed on pills': ['Suicidal ideation'], 'tried to cut wrist': ['Suicidal ideation'], 'hypertension': ['Unspecified essential hypertension'], 'migraine headaches': ['Migraine', 'unspecified']}