Psych D/C Summary

**DATE OF ADMISSION: **20 October 2024 **DATE OF DISCHARGE: **1 November 2024 **IDENTIFICATION:** Mr. John Smith, [insert age] 35-year-old male. He is single, employed as a software engineer, and lives in a rented apartment. He has been in his current living arrangement for the past 2 years. **HISTORY OF PRESENTING ILLNESS:** The patient presented to the emergency department on October 19, 2024, after a reported suicide attempt by overdose. He reported increasing feelings of hopelessness and worthlessness over the past month, with a significant decline in his ability to concentrate at work. He had been experiencing insomnia, with difficulty falling asleep and early morning awakenings. He also reported a loss of interest in activities he previously enjoyed, including socialising with friends and playing video games. He reported feeling overwhelmed by work-related stress and financial difficulties. He denied any history of substance use. The patient stated that he had been feeling this way for the past month, with the symptoms worsening in the last week. The patient stated that he had been feeling this way for the past month, with the symptoms worsening in the last week. The patient was admitted to the psychiatric unit for further evaluation and treatment. DIAGNOSIS AT ADMISSION: Major Depressive Disorder, Severe, with suicidal ideation. INITIAL management plan: Initiate antidepressant medication, provide individual therapy, and monitor for suicidal ideation. **PAST PSYCHIATRIC HISTORY**: 1. No known past psychiatric admissions. **MEDICAL HISTORY**: 1. Hypertension, diagnosed in 2020, managed with Lisinopril 20mg daily. **MEDICATIONS ON ADMISSION:** 1. Lisinopril 20mg daily. **INVESTIGATIONS:** * Complete Blood Count (CBC) - WNL * Comprehensive Metabolic Panel (CMP) - WNL * Urine Drug Screen - Negative **MENTAL STATUS EXAM ON ADMISSION:** - _Appearance:_ Well-groomed, but appeared somewhat disheveled. - _Behaviour:_ Psychomotor retardation, with slowed movements and speech. - _Speech:_ Monotonous, with decreased rate and volume. - _Mood:_ Reported feeling sad and hopeless. - _Affect:_ Restricted, with limited emotional expression. - _Thoughts:_ Preoccupied with feelings of worthlessness and suicidal ideation. - _Perceptions:_ No hallucinations reported. - _Cognition:_ Oriented to person, place, and time. Intact memory. - _Insight:_ Limited insight into his condition. - _Judgment:_ Impaired judgment due to suicidal ideation. **COURSE IN HOSPITAL:** **Problem 1**: The patient was admitted due to a suicide attempt and symptoms of major depressive disorder. During his hospital stay, the patient was started on Sertraline 50mg daily, which was gradually increased to 100mg daily. He participated in individual therapy sessions, where he explored his feelings of hopelessness and developed coping strategies. The patient also attended group therapy sessions focused on managing depression and suicidal ideation. The patient's mood gradually improved, and his suicidal ideation decreased. The patient was also seen by a social worker to discuss aftercare planning. **Problem 2**: The patient reported difficulty sleeping. He was prescribed Trazodone 50mg at bedtime to help with sleep. The patient reported improved sleep quality with the medication. **Problem 3**: The patient reported feeling overwhelmed by work-related stress. The patient was encouraged to discuss his work-related stress with his therapist and was provided with resources for stress management. **DISCHARGE PLAN:** **Problem 1**: The patient will continue taking Sertraline 100mg daily. He will attend outpatient individual therapy sessions twice a week. He will also attend a support group for individuals with depression. The patient was provided with a list of crisis resources. **Problem 2**: The patient will continue taking Trazodone 50mg at bedtime as needed for sleep. **Problem 3**: The patient was provided with resources for stress management and encouraged to continue to use the coping strategies he learned in therapy. **MEDICATIONS ON DISCHARGE:** 1. Sertraline 100mg daily. 2. Trazodone 50mg at bedtime as needed. **MENTAL STATUS EXAM ON DISCHARGE:** - _Appearance:_ Well-groomed. - _Behaviour:_ Normal activity level. - _Speech:_ Normal rate and volume. - _Mood:_ Reporting feeling less sad and more hopeful. - _Affect:_ Appropriate and congruent. - _Thoughts:_ No suicidal ideation reported. - _Perceptions:_ No hallucinations reported. - _Cognition:_ Oriented to person, place, and time. Intact memory. - _Insight:_ Improved insight into his condition. - _Judgment:_ Good judgment. **DIAGNOSIS:** _Primary Diagnosis:_ Major Depressive Disorder, in partial remission. _Secondary Diagnoses:_ History of Hypertension. "It was a pleasure being involved in this patient’s care. Do not hesitate to contact me if you have any questions" Sincerely, Dr. Emily Carter, MD