Subjective:
C.C “ I want to kill myself”
HPI: This patient is a 16 year old female with past psychiatric history of major depressive disorder and oppositional defiance disorder who presented voluntarily, by herself, to Crisis with complaints of suicidal ideation with plan to overdose on medications. The patient reports that she and her mother got into a fight, she feels that her mother does not care about her. The patient has been feeling alone, she has been experiencing anhedonia, difficulty sleeping, low energy, decreased appetite, and difficulty concentrating. Patient has previous suicide attempts by overdose and previous admissions, last admission to CAAP 9/28/22. The patient reports occasional cannabis use, last time being within the last 90 days, however, denies further substance use, tobacco, nicotine, or alcohol use. Patient was previously taking Lexapro 10 mg on previous admission, however states that she stopped taking it when she left here. Patient denies history of physical or sexual abuse.
Patient’s mother, Chantrel McClain (305-915-3816), was spoken to briefly. She reports not knowing that her daughter was here, but stating that she is not surprised because the patient often seeks psychiatric treatment following arguments with her mother. The patient has been reportedly acting normal over the past several weeks and has not been having trouble at school. The patient’s mother states that the patient does not have follow up with a psychiatrist nor a psychologist. Patient’s mother states that she is not welcome back in her house, and instead she would like to see the patient go live with the patient’s father. The patient has not been taking Lexapro 10mg daily which she was discharged on last admission, however, consented for this medication over the phone. Patient has past medical history of ovarian cyst and asthma.
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On interview, patient states that she got into a fight with her mother and afterwards, started to have active and passive suicidal ideations of wanting to overdose and wishing she was never born. Patient reports feeling that her mother pays more attention to her sister and to her mother’s fiance and blames everything on her. Patient would not disclose what specifically caused the argument. Also reported feeling depressed these past couple of weeks and endorsed associated anhedonia, poor sleep/low energy, poor appetite, and altered concentration. States that she feels she is always being blamed by her mother. Reports issues with anxiety and identifies that there is a stressor that potentially contributed to her current symptomatology but patient refused to elaborate. Patient states that she is not currently on medication or established in outpatient therapy.
Otherwise, denies any history of trauma or associated PTSD symptoms. Denies any history of obsessions or compulsions. Denies any history of manic/hypomanic episodes. Denies any auditory/visual hallucinations or delusional beliefs and is not observed to be responding to internal stimuli.
Per collateral, mother states that patient had been staying at her godparent’s house after school more than she is supposed to and not returning home and this is what mother confronting her about yesterday. She states that patient later texted her that she wanted to kill herself. States that she has noticed patient crying a lot more and attributed this to patient’s biological father not sending her any money recently. She is not aware of any other stressors for patient. She confirms that patient is not established in outpatient therapy and is not currently on medication.
Discussed clinical status, risk status, and treatment plan. Guardian expressed verbal understanding and agreement with current plan.
Based on symptoms and behaviors described above:
– There is evidence of symptoms and behavior reflecting impairment, and continued treatment in an inpatient psychiatric setting is warranted at this time
– No less restrictive alternative is presently available
– Patient continues to meet criteria for inpatient admission to BH Unit
Substance Use:
Alcohol: denies
Nicotine: denies
Drug Use: endorses occasional use of marijuana
Detox/Rehab: denies
Exposure to Trauma:
Physical: denies
Sexual: denies
Neglect: denies
Medical History:
Past medical history: asthma and ovarian cyst
Past surgical history: denies
Seizures: denies
Head injury (LOC, TBI, etc): denies
Current nonpsychiatric medications: denies
Psychiatric History/Psychological Evaluation:
Inpatient treatment: a couple in the past
Outpatient treatment: denies
Suicide history: aborted suicide attempts
Nonsuicidal self injurious behavior: denies
Prior medications: fluoxetine and escitalopram
Current psychiatric medications: denies
Developmental History:
Birth History: uncomplicated, vaginal delivery, full term
Developmental Milestones:
Walked at: on time
Talked at: on time
Toilet trained: on time
Emotional development: within normal limits
Social development: within normal limits
Family Medical/Psychiatric History:
Mental illness: denies
Substance abuse: denies
Suicide: denies
Medical: mother has hypertension
Social History:
Born: Miami
Raised by: mother
Siblings: 5 siblings (3 brothers, 2 sisters)
Lives with: mother, sister, and mother’s fiance
Relationships:
Sexually active: denies
Educational History:
Grade: 11th grade
School: Lindsey Hopkins Technical College
Performance: good grades
Suspensions/Expulsions: expelled from previous high school
Bullying: denies
Legal History:
Legal guardian: Mother
History of arrest: denies
Mental Status Exam:
Appearance/Behavior: appears stated age, fair grooming/hygiene, dressed in hospital gown, somewhat guarded and moderately cooperative
Eye Contact: fair
Motor Activity: no PMA/PMR, AIMS absent
Speech: non-spontaneous; normal volume, rate, and prosody
Mood: “depressed”; observed to be dysphoric
Affect: constricted, congruent with stated mood
Thought Process: linear, organized
Thought Content: no preoccupations, no obsessions or compulsions elicited, no phobias elicited, no delusions elicited
Perceptual Disturbances: denies AVTOG hallucinations, does not appear RTIS
Suicidal Ideation/Intent/Plans: endorses passive suicidal ideations
Homicidal Ideation/Intent/Plans: denies
Insight/Judgment: poor/poor
Orientation: alert and oriented to self and situation
Attention/Concentration: fair/fair
Fund of knowledge: average
Memory: not formally evaluated, appears grossly intact
Vital Signs:
Height: 159.2 cm
Weight: 51.9 kg
Temperature Oral: 36.9 DegC
Peripheral Pulse Rate: 69 bpm
Respiratory Rate: 20 br/min
Systolic Blood Pressure: 108 mmHg
Diastolic Blood Pressure: 50 mmHg
Pain Present: No actual or suspected pain
Review of Systems:
Constitutional: does not complain of fever, chills, or fatigue
HEENT: does not complain of vision changes, congestion, or sore throat
Skin: does not complain of rash or itching
Cardiac: does not complain of chest pain or palpitation
Respiratory: does not complain of cough or shortness of breath
Gastrointestinal: does not complain of abdominal pain, nausea, vomiting or diarrhea.
Genitourinary: does not complain of dysuria
Neurological: does not complain of dizziness, headaches, or weakness
Musculoskeletal: does not complain of muscle pain, joint pain, or stiffness
Hematologic: does not complain of easy bleeding or bruising
Scales
none administered at this time
Medical Decision Making:
Differential Diagnoses
Unspecified mood (affective) disorder F39
Oppositional defiant disorder F91.3
Impulse control disorder F63.9
Target Symptoms:
suicidal behavior/ideation
depression
non-adherent behaviors
temper outbursts
Treatment Recommendations/Plan:
1) Occupational/Recreational/Activity Therapy: will participate
2) School: will attend
3) Scales: none at this time
4) Information: previous records, school information
5) Studies to be ordered: none
6) Consults: none
7) Precautions: level 1
8) Individual sessions: psychoeducation, safety, coping skills
9) Family sessions: psychoeducation, safety, length of stay
10) Suicide risk: low in the unit, no 1:1 sitter required at this time
11) Medications:
– Starting escitalopram 5 mg daily for mood/anxiety
PRNs are in place
12) Aftercare planning: medication management, individual therapy
13) Estimated length of stay: guarded
Make sure all these are completed:
Discuss Subjective data:• Chief complaint• History of present illness (HPI)• Medications• Psychotherapy or previous psychiatric diagnosis• Pertinent histories and/or ROS
Discuss Objective data:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
Discuss results of Assessment:• Results of the mental status examination• Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and is supported by the patient’s symptoms.
Discuss treatment Plan:• A treatment plan for the patient that addresses chosen FDA-approved psychopharmacologic agents and includes alternative treatments available and supported by valid research. The treatment plan includes rationales, a plan for follow-up parameters, and referrals. The discussion includes one social determinant of health according to the HealthyPeople 2030, one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health.
This criterion is linked to a Learning OutcomeReflect on this case. Discuss what you learned and what you might do differently.
