Scribe BC - ER Psych Consult

**IDENTIFICATION:** J.S., [insert age] 28-year-old female. The patient is currently unemployed and lives with her parents. She completed high school and has no further education. She reports being single and has no children. She has lived with her parents for the past 6 months, prior to that she was living in a shared apartment. She is not currently working or attending school. **REASON FOR REFERRAL:** Suicidality **CHIEF COMPLAINT:** “I want to die.” **HISTORY OF PRESENTING ILLNESS:** The patient presents to the emergency department today with acute suicidal ideation. She reports feeling overwhelmed and hopeless, stating she has been experiencing these feelings for the past two weeks. She reports a significant increase in her anxiety and depressive symptoms over the past week. She reports feeling worthless and has been isolating herself from friends and family. She reports difficulty sleeping, with insomnia nearly every night. She denies any changes in appetite. She reports that she has been having thoughts of self-harm, including thoughts of jumping off a bridge. She denies any history of self-harm. She reports that she has been feeling this way since she lost her job two weeks ago. She denies any history of previous psychiatric treatment. (Situation): The patient was brought to the emergency department by her parents after they found her crying and expressing suicidal thoughts. She had locked herself in her room and refused to come out. The parents called emergency services, who brought her to the hospital for evaluation. She was assessed by the triage nurse and placed on a mental health watch. (Stressors): The patient reports significant stress related to her recent job loss. She feels she is a failure and is worried about her financial situation. She also reports feeling pressure from her parents to find a new job quickly. She reports that she feels like she is a burden to her family. (Symptoms): * Mood: Depressed mood, feelings of hopelessness, worthlessness. * Anxiety: Increased anxiety, feeling overwhelmed. * Safety: Suicidal ideation with plan (jumping off a bridge). (Safety): The patient reports active suicidal ideation with a plan to jump off a bridge. She denies any intent to harm others. (Substance Use): The patient denies any current use of alcohol, cannabis, stimulants, opioids, or other drugs. She denies any history of substance use. (Current Supports): The patient is not currently seeing a psychiatrist or therapist. She has no structured support for her mental health. (Collateral): The patient's parents were present and provided additional information. They confirmed the patient's recent job loss and expressed concern about her mental state. They reported that the patient has been withdrawn and irritable over the past two weeks. **PAST PSYCHIATRIC HISTORY:** **MEDICAL HISTORY:** 1. No known medical conditions. **MEDICATIONS:** 1. None. **ALLERGIES:** No Known Drug Allergies **FAMILY HISTORY**: Mother: History of depression. Father: No known psychiatric history. **BRIEF PSYCHOSOCIAL HISTORY:** The patient was born in London, UK. She has one sibling, a younger brother. She reports a generally positive childhood, but recalls feeling pressure to succeed academically. Her parents are supportive but can be overbearing. She has never experienced physical, emotional, or sexual abuse. She completed high school and has not pursued further education. She has worked in retail for the past five years. She has been in a relationship for two years, but it ended six months ago. The major life event was the loss of her job two weeks ago. **MENTAL STATUS EXAM (MSE):** - Appearance: The patient appears dishevelled, with unkempt hair and clothing. She appears her stated age. - Behaviour: The patient is restless and fidgety, pacing in the room. She is tearful and appears distressed. - Speech: The patient's speech is normal in rate and volume, but she speaks with a soft tone. Her speech is coherent. - Mood: The patient reports feeling “sad” and “hopeless.” - Affect: The patient's affect is congruent with her stated mood. She displays a constricted range of affect. - Thought Process: The patient's thought process is linear and goal-directed. - Thought Content: The patient reports suicidal ideation with a plan. She denies any homicidal ideation, delusions, or hallucinations. - Perceptions: No hallucinations reported. - Cognition: The patient is alert and oriented to person, place, and time. Her memory appears intact. - Insight: The patient acknowledges that she is experiencing a mental health crisis. - Judgment: The patient's judgment appears impaired due to her suicidal ideation. **IMPRESSION:** Primary Diagnosis: Major Depressive Disorder, Severe, with Suicidal Ideation. **PLAN:** 1. **Safety**: The patient is at high risk for suicide and requires immediate intervention. The patient is an indication for psychiatric admission. The patient needs to be certified. 2. **Biological**: Order a comprehensive metabolic panel (CMP), complete blood count (CBC), and urine drug screen (UDS). Start the patient on an antidepressant medication, such as sertraline, and an anxiolytic medication, such as lorazepam, as needed. Consult with the on-call psychiatrist. 3. **Psychosocial**: Refer the patient to a psychiatrist for ongoing care. Refer the patient to a therapist for individual therapy. Encourage the patient to attend support groups. Contact the patient's parents to provide support and education. “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.”