**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 He had been experiencing difficulty concentrating at work and had withdrawn from social activities.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.”
