“The patient/family provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks.”
**IDENTIFYING INFORMATION:**
Mrs. Evelyn Reed, [insert age] years old, is a widowed female who lives in a supported living facility. She was referred to the Older Adult Mental Health Unit (OAMHU) at RCH by her primary care physician due to worsening depressive symptoms and suicidal ideation.
**HPI:**
Mrs. Reed presents with a two-month history of depressed mood, anhedonia, and significant social withdrawal. She reports feeling hopeless and worthless, with increasing thoughts of wanting to end her life. She denies any previous history of suicidal attempts. She reports poor sleep, decreased appetite, and a 10-pound weight loss over the past month. She denies any current substance use. She reports that her symptoms started after the anniversary of her husband's death.
**COLLATERAL INFORMATION: **
Ms. Sarah Miller, the patient's daughter, reports that her mother has been increasingly withdrawn and tearful in recent weeks. She states that her mother has stopped participating in activities she used to enjoy and has expressed feeling like a burden. Ms. Miller also reports that her mother has been neglecting her personal hygiene and has stopped taking her medications as prescribed.
Mr. John Smith, the patient's care worker, reports that Mrs. Reed has become increasingly agitated and irritable. He has observed her pacing in her room and expressing feelings of hopelessness. He also reports that she has refused meals on several occasions.
**Past Psych:**
- Admitted to OAMHU 5 years ago for a major depressive episode. Discharged after 6 weeks with improvement in symptoms.
- No previous history of inpatient psychiatric admissions.
- Previous trials of sertraline 50mg daily, which was discontinued due to side effects.
**Past Medical History:**
- Hypertension
- Osteoarthritis
- Hypothyroidism
- Allergies: NKDA
- Medications: Lisinopril 10mg daily, Levothyroxine 50mcg daily, and over-the-counter medications for arthritis.
**Social History:**
Mrs. Reed was a teacher before retiring. She was married for 50 years before her husband passed away. She has one daughter, Sarah, who lives nearby and provides some support. She has limited contact with other family members. She has a strong religious faith and attends church regularly. She receives financial support from her pension and social security. She denies any history of abuse or trauma. Her current living environment is a supported living facility.
**Substance Use history:**
Denies any history of alcohol or illicit drug use. She denies any history of prescription medication misuse.
**Family Psychiatric History:**
Mother had a history of depression, treated with medication. No other family history of psychiatric illness.
**Current Medications:**
- Lisinopril 10mg daily
- Levothyroxine 50mcg daily
- Over-the-counter pain relievers for arthritis
**Mental Status Examination: **
Appearance: The patient is a well-groomed elderly woman, appearing her stated age. She is dressed in clean, appropriate clothing. Her hygiene is adequate.
Behavior: The patient is sitting in her chair, appearing restless and fidgety. She makes limited eye contact. She is cooperative with the interview.
Speech: Speech is normal in rate and volume. Speech is clear and coherent.
Mood: The patient reports feeling “very sad” and “hopeless.”
Affect: Affect is constricted and congruent with mood.
Thoughts: The patient expresses recurrent thoughts of wanting to die. She denies any current suicidal plan. She denies any homicidal ideation. No evidence of psychosis.
Perceptions: The patient was not observed to be attending to internal stimuli and denied any auditory or visual hallucinations.
Cognition: The patient is oriented to person, place, and time. Her memory is intact. Her concentration is slightly impaired. She is able to follow simple instructions.
Insight: The patient acknowledges that she is depressed and that her symptoms are affecting her life.
Judgment: The patient's judgment appears to be impaired due to her depressed mood.
**Investigations:**
- Complete blood count (CBC) and comprehensive metabolic panel (CMP) pending.
- Thyroid function tests (TFTs) pending.
- ECG pending.
**IMPRESSION:**
Major Depressive Disorder, severe, with suicidal ideation. The patient's presentation is consistent with a major depressive episode, likely triggered by the anniversary of her husband's death and compounded by social isolation and chronic medical conditions. The risk of suicide is elevated.
**Plan:**
1. Certification
The patient is admitted under Section 2 of the Mental Health Act. Review date in 28 days.
2. Safety
- Close observation, including regular checks by nursing staff.
- Suicide precautions, including removal of potential means of self-harm.
- One-to-one observation as needed.
3. Biological
- Initiate antidepressant medication, such as escitalopram 10mg daily, with dose adjustments as needed.
- Monitor for side effects and therapeutic response.
- Consider adjunctive medications for sleep and anxiety as needed.
4. Psychosocial
- Individual therapy to address grief, loss, and coping skills.
- Group therapy to promote social interaction and support.
- Family therapy to involve the patient's daughter in the treatment plan.
- Social work to assess social support and discharge planning.
5. Disposition
- Estimated length of stay: 4-6 weeks.
- Discharge to the supported living facility.
- Follow-up with outpatient psychiatry and therapy.
- Referral to community support services.
“It has been a pleasure being a part of the care for this patient. If there are any questions, please do not hesitate to contact me. ”
“Dr. Thomas Kelly”
Geriatric Psychiatrist
