CL psych consult

**IDENTIFICATION:** J.S., 34-year-old female, completed high school, employed as a teacher, single, no children, living in an apartment. Currently on leave from work for the past two weeks due to increased anxiety and panic attacks. **REASON FOR ADMISSION:** Admitted to hospital due to suicidal ideation and a suicide attempt. **REASON FOR REFERRAL:** Psychiatric consultation requested to assess and manage acute suicidal risk. **CHIEF COMPLAINT:** “I don’t want to feel this way anymore. I just want the pain to stop.” **HISTORY OF PRESENTING ILLNESS:** _Situation leading to hospitalization_: Patient reports a gradual increase in anxiety and panic attacks over the past month, culminating in a suicide attempt by overdose of prescribed medication. She reports feeling overwhelmed by work-related stress and relationship difficulties. She was brought to the emergency department by ambulance after being found by a neighbour. _Situation since hospitalization_: Patient has been admitted to the psychiatric ward for observation and treatment. She has been started on intravenous fluids and is being monitored for any physical complications from the overdose. She has been seen by the medical team and the nursing staff. _Stressors_: Work-related stress, financial difficulties, and recent breakup with her partner. _Symptoms_: * Mood: Reports feeling persistently sad, hopeless, and irritable. Denies any periods of elevated mood or mania. * Anxiety: Experiencing frequent panic attacks, characterised by palpitations, shortness of breath, and fear of dying. Reports generalized anxiety and worry about her future. * Safety: Reports active suicidal ideation with intent and a plan. Denies homicidal ideation. _Safety_: Patient reports current suicidal ideation with intent and plan. She reports a previous suicide attempt by overdose. _Substance Use_: Denies current use of alcohol or illicit drugs. Reports occasional use of cannabis in the past, but not in the last six months. _Current Supports_: Currently involved in individual therapy with a therapist and has a primary care physician. _Patient Interaction_: Patient is cooperative and appears distressed. She is able to answer questions appropriately but struggles to maintain eye contact. She expresses remorse for her actions and a desire to feel better. She states, “I just want to feel normal again.” _Collateral - Personal_: The patient’s mother was contacted and reported that the patient has a history of anxiety and depression. She also reported that the patient has been struggling with work-related stress and relationship difficulties. _Collateral - Health care providers_: The patient’s therapist has provided a summary of the patient’s history and treatment. She has recommended that the patient be admitted to the hospital for further evaluation and treatment. **PAST PSYCHIATRIC HISTORY:** 1. Diagnosed with Major Depressive Disorder and Generalized Anxiety Disorder five years ago. 2. History of self-harm by cutting, but no attempts in the last two years. _Past psychiatric hospitalizations_: One prior psychiatric hospitalization two years ago for a suicide attempt by overdose. **MEDICAL HISTORY**: No significant medical history reported. **HOME MEDICATIONS:** 1. Sertraline 100mg daily. 2. Alprazolam 0.5mg as needed for anxiety. **HOSPITAL MEDICATIONS:** 1. Sertraline 100mg daily. 2. Lorazepam 1mg every 6 hours as needed for anxiety. **ALLERGIES:** No Known Drug Allergies. **FAMILY HISTORY**: Mother has a history of depression. Father has a history of alcohol use disorder. **BRIEF PSYCHOSOCIAL HISTORY:** Born and raised in London, England. Only child. Upbringing was stable. Completed education up to high school. Employed as a teacher. Has been in a relationship for 2 years, recently ended. No history of abuse. **INVESTIGATIONS:** Complete blood count, comprehensive metabolic panel, and urine drug screen ordered. Results pending. **MENTAL STATUS EXAM (MSE):** * _Appearance:_ Appears her stated age. Well-groomed but tearful. * _Behaviour:_ Cooperative but restless, frequently fidgeting. * _Speech:_ Normal rate and volume, clear, coherent. * _Mood:_ Subjectively reports feeling sad and hopeless. * _Affect:_ Restricted affect, congruent with mood. * _Thought Process:_ Linear and goal-directed. * _Thought Content:_ Preoccupied with feelings of worthlessness and hopelessness. Reports suicidal ideation with intent and plan. Denies homicidal ideation. * _Perceptions:_ No hallucinations reported. * _Cognition:_ Oriented to person, place, and time. Intact memory and concentration. * _Insight:_ Demonstrates some insight into her condition, acknowledging the need for treatment. * _Judgment:_ Judgment appears impaired due to suicidal ideation. **IMPRESSION:** _Primary Diagnosis:_ Major Depressive Disorder, Severe, with Suicidal Ideation. _Secondary Diagnoses:_ Generalized Anxiety Disorder. **PLAN:** 1. **Safety**: Continue inpatient psychiatric care. Implement one-to-one observation. Assess for risk daily. 2. **Biological**: Continue current medications. Order repeat labs. Consider medication adjustment. 3. **Psychosocial**: Refer to individual therapy and group therapy. Involve family in treatment planning. "It was a pleasure being involved in this patient’s care. Do not hesitate to contact me if you have any questions" Sincerely, Dr. Eleanor Vance, MD