OAMHU Discharge Summary

Date of Discharge: 1 November 2024 **Presenting Problem / Reason For Admission:** The patient presented to the emergency department with acute suicidal ideation and a recent suicide attempt by overdose. The patient reported feeling overwhelmed by stress related to work and relationship difficulties, and expressed a desire to end their life. **Course of Hospitalization:** The patient was admitted to the inpatient psychiatric unit for safety and stabilisation. During the hospital stay, the patient received individual therapy, group therapy, and medication management. The patient's suicidal ideation gradually decreased, and they began to engage more actively in treatment. The patient's medication regimen was adjusted to include an antidepressant and an anxiolytic. The patient showed improvement in mood and a reduction in anxiety levels. No complications were noted during the hospital stay. **Mental Status Examination:** Appearance: The patient appeared their stated age and was well-groomed. They were dressed in clean, casual clothing. Behaviour: The patient was cooperative and displayed normal psychomotor activity. They were able to maintain eye contact during the interview. Speech: The patient's speech was normal in rate, volume, and clarity. The patient was coherent and goal-directed. Mood: The patient reported feeling sad and anxious, but also expressed some hope for the future. Affect: The patient's affect was congruent with their stated mood, with a range of emotions expressed appropriately. Thoughts: The patient's thought process was linear and logical. There was no evidence of psychosis, delusions, or hallucinations. Perceptions: Patient was not observed to be attending to internal stimuli and denied any auditory or visual hallucinations. Cognition: The patient was alert and oriented to person, place, and time. Their memory and concentration were intact. Insight: The patient demonstrated a good understanding of their condition and the need for ongoing treatment. Judgment: The patient demonstrated good judgment and an understanding of the consequences of their actions. **Discharge Diagnoses:** - Primary Psychiatric Diagnosis: Major Depressive Disorder, Recurrent, Severe, with Psychotic Features (F33.3) - Secondary/Medical Diagnoses: Generalized Anxiety Disorder (F41.1) **Medications at Discharge:** - Sertraline 100mg daily, PO, for depression. - Clonazepam 0.5mg twice daily, PO, for anxiety. **Disposition:** - Discharge Setting: Home - Living Situation: With family - Support System: The patient has a supportive family and a close friend who will provide emotional support and assist with medication adherence. **Discharge Risk Assessment:** The patient's risk of suicide and self-harm was assessed as low at discharge. The patient has a supportive family and a good understanding of their condition. The patient has a crisis plan in place and is committed to attending follow-up appointments. **Follow-up and Aftercare Plan:** - Psychiatric Follow-up: Dr. Emily Carter, Psychiatrist, within one week. - Therapy/Counseling: Individual therapy with Dr. Sarah Jones, LCSW, weekly. - Medical Follow-up: Primary care physician within two weeks. - Referrals: Referral to a local support group for individuals with depression. - Crisis Plan: The patient has been provided with a crisis plan that includes emergency contact information and instructions for what to do in the event of a psychiatric crisis. **Discharge Instructions:** The patient was instructed to continue taking their medications as prescribed, attend all scheduled appointments, and contact their psychiatrist or therapist immediately if they experience any worsening of symptoms or suicidal thoughts. The patient was also provided with information about local mental health resources and support groups. **Discharging Clinician:** Dr. Thomas Kelly, MD, Psychiatrist