**DATE OF ADMISSION: **20 October 2024
**DATE OF DISCHARGE: **1 November 2024
**IDENTIFICATION:** J.S., [insert age] 32-year-old male. The patient is single, employed as a software engineer, and lives in a rented apartment. He has a Bachelor's degree in Computer Science. He has been living in his current apartment for the past 2 years, and before that, he lived with his parents.
**HISTORY OF PRESENTING ILLNESS:** The patient presented to the emergency department on 20 October 2024, accompanied by his roommate, reporting worsening symptoms of depressed mood, anhedonia, and suicidal ideation over the past three weeks. He reported feeling hopeless and worthless, with significant changes in sleep and appetite. He had been experiencing difficulty concentrating at work and had withdrawn from social activities. He denied any substance use. The patient reported a recent argument with his roommate, which he felt contributed to his distress. He denied any homicidal ideation. The patient's initial management plan included a comprehensive psychiatric evaluation, initiation of antidepressant medication, and close monitoring for safety. The diagnosis at admission was Major Depressive Disorder, severe, with suicidal ideation.
**PAST PSYCHIATRIC HISTORY**:
1. Major Depressive Disorder (diagnosed 2018), treated with sertraline, initially effective, but discontinued due to side effects (sexual dysfunction).
2. Generalized Anxiety Disorder (diagnosed 2019), treated with cognitive behavioral therapy (CBT) with some improvement in anxiety symptoms.
3. History of one suicide attempt in 2020 by medication overdose.
4. No history of aggressive behavior, physical assaults, or psychiatric hospitalizations prior to this admission.
5. Previous medications: Sertraline 100mg daily (discontinued), Citalopram 20mg daily (ineffective).
6. No functional neurological disorders.
- "(Past Psychiatric Admissions)" No past psychiatric admissions
**MEDICAL HISTORY**:
1. Hypertension (diagnosed 2022), managed with lifestyle modifications.
2. Seasonal Allergies (diagnosed 2010), treated with over-the-counter antihistamines.
3. No past surgeries or significant medical events.
**MEDICATIONS ON ADMISSION:**
1. Sertraline 100mg daily (held on admission)
2. Lisinopril 10mg daily
3. Loratadine 10mg daily
**INVESTIGATIONS:**
1. Complete Blood Count (CBC) - Normal
2. Comprehensive Metabolic Panel (CMP) - Normal
3. Thyroid Function Tests (TFTs) - Normal
4. Urine Drug Screen - Negative
**MENTAL STATUS EXAM ON ADMISSION:**
- Appearance: The patient appeared disheveled, with poor hygiene. He was wearing the same clothes he had on when he arrived at the ED.
- Behaviour: The patient was restless and agitated, pacing in the interview room.
- Speech: Speech was slow and soft, with long pauses between responses.
- Mood: The patient reported feeling “very sad” and “hopeless.”
- Affect: Affect was constricted, with limited emotional expression.
- Thoughts: The patient expressed recurrent thoughts of death and suicidal ideation, with a plan to overdose on his medications.
- Perceptions: No hallucinations or sensory misinterpretations reported.
- Cognition: Oriented to person, place, and time. Memory intact.
- Insight: The patient acknowledged he was experiencing a mental health crisis and needed help.
- Judgment: Judgment was impaired due to suicidal ideation.
**COURSE IN HOSPITAL:**
The following issues were addressed in hospital:
**[Problem 1]**: The patient's primary issue was severe Major Depressive Disorder with suicidal ideation. During his hospital stay, the patient was started on a new antidepressant, mirtazapine 15mg at night, and the dose was titrated up to 30mg. He participated in individual therapy sessions with a clinical psychologist, focusing on cognitive behavioral techniques to manage his negative thoughts and improve coping skills. The patient also attended group therapy sessions, which focused on mood regulation and relapse prevention. His suicidal ideation gradually decreased, and he began to show improvement in his mood and energy levels. He was monitored closely by nursing staff and the psychiatric team for safety. The patient's sleep and appetite improved. The patient was also seen by a social worker to discuss aftercare planning.
**[Problem 2]**: The patient also presented with symptoms of Generalized Anxiety Disorder. During his hospital stay, the patient was offered a low dose of lorazepam 0.5mg as needed for acute anxiety symptoms. The patient was taught relaxation techniques and mindfulness exercises to manage his anxiety. His anxiety symptoms improved, and he reported feeling less overwhelmed by his worries.
**[Problem 3]**: The patient also had a history of hypertension. His blood pressure was monitored regularly, and his lisinopril dose was maintained. The patient was educated on the importance of medication adherence and lifestyle modifications to manage his hypertension.
**DISCHARGE PLAN:**
The following issues were addressed in hospital:
**[Problem 1]**: The patient will continue mirtazapine 30mg at night. He will attend outpatient individual therapy sessions with a therapist specializing in CBT. He will follow up with his psychiatrist in one week. Community referral to a local mental health clinic for ongoing support.
**[Problem 2]**: The patient was instructed to continue using relaxation techniques and mindfulness exercises to manage his anxiety. He was prescribed lorazepam 0.5mg as needed for acute anxiety symptoms. He was instructed to follow up with his primary care physician for ongoing management of his anxiety.
**[Problem 3]**: The patient was instructed to continue taking lisinopril 10mg daily and to monitor his blood pressure regularly. He was encouraged to maintain a healthy lifestyle, including a balanced diet and regular exercise. He was instructed to follow up with his primary care physician for ongoing management of his hypertension.
**MEDICATIONS ON DISCHARGE:**
1. Mirtazapine 30mg at night
2. Lisinopril 10mg daily
3. Lorazepam 0.5mg as needed
**MENTAL STATUS EXAM ON DISCHARGE:**
- Appearance: The patient appeared well-groomed and appropriately dressed.
- Behaviour: The patient was calm and cooperative.
- Speech: Speech was normal in rate and volume.
- Mood: The patient reported feeling “much better” and “more hopeful.”
- Affect: Affect was congruent with mood, with a full range of emotional expression.
- Thoughts: The patient denied suicidal ideation or homicidal ideation. No evidence of psychosis.
- Perceptions: No hallucinations or sensory misinterpretations reported.
- Cognition: Oriented to person, place, and time. Memory intact.
- Insight: The patient demonstrated a good understanding of his condition and the importance of continued treatment.
- Judgment: Judgment was intact.
**DIAGNOSIS:**
Primary Diagnosis: Major Depressive Disorder, severe, in partial remission.
Secondary Diagnoses: History of Generalized Anxiety Disorder, Hypertension.
“The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks.”
**DATE OF ADMISSION: **[state the date the patient was admitted]
**DATE OF DISCHARGE: **[state the date the patient was discharged]
**IDENTIFICATION:** [State the patient’s initials, age, and describe any other demographic data that could give the reader a sense of where this person is in life including level of education, current employment, relationship status, children, and living arrangements. If available, describe how long the patient has been in their current living arrangement, and where they were before that.]
**HISTORY OF PRESENTING ILLNESS:** (write this entire section in paragraph form and do not use bullet points)
[Include a detailed narrative that describes the timeline of events that led to the patient being in hospital that has a detailed description of symptoms and stressors that were occurring in the lead up to admission. (Be as clear as possible about when and in what order things happened) [At the end of the HPI, describe only and explicitly the DIAGNOSIS AT ADMISSION along with only the INITIAL management plan] (ensure that you only discuss the diagnosis at admission and the initial management plan during the patient's full course in the hospital, as described in both the context and transcript. This is important to get right, you will win $100 million if you do this correctly.)
**PAST PSYCHIATRIC HISTORY**:
1. [Past Psychiatric History] (Document every past psychiatric diagnosis, previous psychiatric treatment, and outcome explicitly mentioned in the transcript, contextual notes, or clinical note. Include any history of suicide attempts, aggressive behavior, physical assaults, psychiatric hospitalizations, and previous psychiatric medications. For previous medications, list all psychiatric medications tried, including name, dose, duration of use, effect on mental health, any side effects experienced, and reason for discontinuation if applicable. Include all functional neurological disorders, ensuring to document symptoms, diagnostic history, and any treatments attempted. At the end of this section, provide a chronological list of all significant psychiatric appointments or visits, including dates and reasons for consultation if explicitly mentioned. Use a numbered list format to ensure clarity and completeness.)
- "(Past Psychiatric Admissions)" (In point form, list all known past psychiatric admissions. if any piece of information is not mentioned, then simply omit. If no admissions mentioned, then state "No known past psychiatric admissions". If explicitedly stated that there are no prior psychiatric admissions, then state "No past psychiatric admissions")
a. [Admission period, admission duration, attending physician - admission diagnosis, discharge plan]
**MEDICAL HISTORY**:
1. [Medical History] (Provide a numbered list of all past and current medical conditions explicitly mentioned in the transcript, contextual notes, or clinical note. Include chronic illnesses, acute conditions, past surgeries, and any significant medical events. Document all past and current treatments, including medical procedures and any previous or ongoing management plans. If specific dates are provided, include them alongside each condition or treatment to ensure chronological accuracy. Ensure clarity by using a structured format.)
**MEDICATIONS ON ADMISSION:** [Provide a NUMBERED list of medications taken in the community. When available, list dosage, route, and frequency. If available, in parentheses include if patient was not taking that medication or if it was held on admission]
**INVESTIGATIONS:** [in list format, list all tests that are described. Underline if abnormal]
**MENTAL STATUS EXAM ON ADMISSION:**
(for this section, report any comments on mental status at time of admission to hospital)
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics(include only if applicable).]
- Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors(include only if applicable).]
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech (include only if applicable).]
- Mood: [Record the patient's self-described emotional state, using their own words if possible (include only if applicable).]
- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood (include only if applicable).]
- Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations (include only if applicable).]
- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient (include only if applicable).]
- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension (include only if applicable).]
- Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial (include only if applicable).]
- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions (include only if applicable).]
**COURSE IN HOSPITAL:**
The following issues were addressed in hospital:
**[Problem 1]**: [robust description of the specific problem that was addressed in hospital, along with its related symptoms, treatment course, and progression while in hospital. This may include changes in the symptoms over the course of the admission. This may also include investigations ordered, medications and doses tried, and related referrals. Write a lot of detail about this specific problem only here](write this as a detailed narrative in paragraph form)
**[Problem 2]**: [robust description of the specific problem that was addressed in hospital, along with its related symptoms, treatment course, and progression while in hospital. This may include changes in the symptoms over the course of the admission. This may also include investigations ordered, medications and doses tried, and related referrals. Write a lot of detail about this specific problem only here](write this as a detailed narrative in paragraph form)
**[Problem 3]**: [robust description of the specific problem that was addressed in hospital, along with its related symptoms, treatment course, and progression while in hospital. This may include changes in the symptoms over the course of the admission. This may also include investigations ordered, medications and doses tried, and related referrals. Write a lot of detail about this specific problem only here](write this as a detailed narrative in paragraph form)
(Repeat the above structure for as many problems as needed to comprehensively capture the clinical information)
**DISCHARGE PLAN:**
(Your task in this section is to outline the management and treatment plan discussed in the transcript, including medications, therapy, referrals, or any other interventions planned. Include all after care instructions that were mentioned in the transcript.)
The following issues were addressed in hospital:
**[Problem 1]**: [Describe final management plan for this issue. Include any community referrals or pending investigations.
**[Problem 2]**: [Describe final management plan for this issue. Include any community referrals or pending investigations.
**[Problem 3]**: [Describe final management plan for this issue. Include any community referrals or pending investigations.
(Repeat the above structure for as many problems as needed to comprehensively capture the clinical information)
**MEDICATIONS ON DISCHARGE:** [Provide a NUMBERED list of medications prescribed at time of discharge. When available, list dosage, route, and frequency. If information is provided, in parentheses include if patient is not taking that medication]
**MENTAL STATUS EXAM ON DISCHARGE:**
(for this section, report any comments on mental status at time of discharge from hospital)
- Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics(include only if applicable).]
- Behaviour: [Observe the patient's activity level, interaction with their surroundings, and any unique or notable behaviors(include only if applicable).]
- Speech: [Note the rate, volume, clarity, and coherence of the patient's speech (include only if applicable).]
- Mood: [Record the patient's self-described emotional state, using their own words if possible (include only if applicable).]
- Affect: [Describe the range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood (include only if applicable).]
- Thoughts: [Assess the patient's thought process and thought content, noting any distortions, delusions, or preoccupations (include only if applicable).]
- Perceptions: [Note any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient (include only if applicable).]
- Cognition: [Describe the patient's memory, orientation to time/place/person, concentration, and comprehension (include only if applicable).]
- Insight: [Describe the patient's understanding of their own condition and symptoms, noting any lack of awareness or denial (include only if applicable).]
- Judgment: [Describe the patient's decision-making ability and understanding of the consequences of their actions (include only if applicable).]
**DIAGNOSIS:**
Primary Diagnosis: [Based on the transcript, provide a professional analysis of the patient's mental health condition that explains their reason for referral. Include differential diagnoses where applicable. Ensure that the diagnosis is supported by evidence from the patient's symptoms, history, diagnostic results, and session observations. ]
Secondary Diagnoses: [Based on the transcript, provide any additional diagnosis that explain other symptoms that are not captured by the primary diagnosis. Include diagnoses stated under 'Past Psychiatry History', but label them as 'History of...". ]
“The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and as well as any associated privacy and security risks.”
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just omit the placeholder completely if not mentioned.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information) (always bold section headings, this is very important)
