ER psych consult

**IDENTIFICATION:** J.S., [insert age] years old, is a single male with no children, currently unemployed, and living in a shared apartment. He completed high school. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **REASON FOR REFERRAL:** The patient was referred for a psychiatric consult due to suicidal ideation and a recent suicide attempt. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **CHIEF COMPLAINT:** "I want to die." (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **HISTORY OF PRESENTING ILLNESS:** (You must document this entire section in paragraph form. Be extremely detailed. Clearly document all symptoms (pertinent negatives and pertinent positives), relevant history, and details about current medical symptoms, including duration, severity, and any triggering events. Provide an exceptionally detailed timeline and narrative of the patient's psychiatric symptoms as per the DSM-5. Document any changes in symptoms since the last visit, focusing on the timeline of when the patient began experiencing their current mental health concerns.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) _(Situation)_: The patient presented to the emergency department on 1 November 2024, after a suicide attempt by overdose. He was found by a friend and brought to the hospital. He was initially assessed by the emergency medical team, who administered activated charcoal. He was then transferred to the psychiatric emergency services for further evaluation. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) _(Stressors)_: The patient reports significant financial difficulties and recent job loss as major stressors contributing to his current mental state. He also mentions relationship problems with his family. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) _(Symptoms)_: * _Mood_: The patient reports feeling persistently sad, hopeless, and experiencing anhedonia. He also reports feeling irritable and restless. * _Anxiety_: The patient reports significant anxiety, including racing thoughts and difficulty concentrating. * _Psychosis_: NOT REPORTED. * _Mania_: NOT REPORTED. * _Personality Disorder_: NOT REPORTED. * _Trauma Related Disorder_: NOT REPORTED. * _Eating Disorder_: NOT REPORTED. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) _(Safety)_: The patient admits to active suicidal ideation with a plan to overdose again. He denies homicidal ideation. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) _(Substance Use)_: The patient reports occasional alcohol use and daily cannabis use. He denies the use of stimulants or opioids. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) _(Current Supports)_: The patient is not currently seeing a psychiatrist or therapist. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) _(Collateral)_: NOT REPORTED. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **PAST PSYCHIATRIC HISTORY:** 1. Major Depressive Disorder, diagnosed in 2020. 2. Generalized Anxiety Disorder, diagnosed in 2018. 3. History of self-harm behaviours including cutting, starting at age 16. 4. Suicidal ideation and attempts. (Only include if explicitly mentioned in transcript or context; otherwise omit section entirely. Write as numbered list.) **Past psychiatric hospitalizations:** * *_2020_*: Admitted to a psychiatric unit following a suicide attempt by overdose. The patient reported feeling hopeless and overwhelmed. He was discharged with a prescription for an antidepressant and a referral for outpatient therapy. (Only include if explicitly mentioned in transcript or context; otherwise omit section entirely. Write in paragraph format, one paragraph per hospitalization.) **MEDICAL HISTORY:** 1. Hypertension. 2. Hyperlipidemia. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Provide a numbered list of all past and current medical conditions explicitly mentioned. 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.) **MEDICATIONS:** 1. Sertraline 100mg daily. 2. Lisinopril 20mg daily. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **ALLERGIES:** No known drug allergies. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **FAMILY HISTORY**: Mother: History of depression. Father: History of alcohol use disorder. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **BRIEF PSYCHOSOCIAL HISTORY:** The patient was born and raised in a suburban area. He has one sibling. His childhood was marked by some conflict with his parents. He reports a history of emotional abuse. He completed high school and has worked in various jobs. He has had several short-term romantic relationships. He reports recent job loss and financial difficulties as major life events. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **MENTAL STATUS EXAM (MSE):** * _Appearance_: The patient appears disheveled and unkempt. * _Behaviour_: The patient is restless and fidgety. * _Speech_: Speech is normal rate and volume, but with a sad tone. * _Mood_: The patient reports feeling sad and hopeless. * _Affect_: Affect is constricted and congruent with mood. * _Thought Process_: Thought process is linear and goal-directed. * _Thought Content_: The patient reports suicidal ideation with a plan. No homicidal ideation or delusions. * _Perceptions_: No hallucinations reported. * _Cognition_: Oriented to person, place, and time. Intact memory and concentration. * _Insight_: The patient acknowledges his mental health condition. * _Judgment_: Judgment is impaired due to suicidal ideation. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **IMPRESSION:** _Primary Diagnosis_: Major Depressive Disorder, Severe, with Suicidal Ideation. _Secondary Diagnoses_: Generalized Anxiety Disorder, History of self-harm. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **PLAN:** 1. **Safety**: The patient is at high risk for suicide and requires immediate psychiatric admission. The patient needs to be certified. 2. **Biological**: Order a comprehensive metabolic panel and a complete blood count. Initiate an antidepressant medication and consider a mood stabilizer. Consult with the internal medicine team. 3. **Psychosocial**: Refer the patient to individual therapy and support groups. Obtain collateral information from the patient's family. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) "It was a pleasure being involved in this patient’s care. Do not hesitate to contact me if you have any questions Sincerely, Dr. Jane Doe, MD" (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)