H&P 1

CC: Suicidal Ideations and Depression

HPI

31 y/o female with no PMH and no past psych history brought in by EMS for questionable suicide attempt with cyclobenzaprine. EMS was called by the patient’s work counselor who was told she took 8-10 pills of cyclobenzaprine on Sunday so she could “sleep for a long time” because she “didn’t want to deal with life”. Prior to taking pills, she states she was coming home from a work trip and felt anxious and heart palpitations, which prompted her to call her counselor 2 days later on Tuesday. Pt stated she has been feeling depressed and overwhelmed since March. She works as a flight attendant for American Airlines and took a leave of absence from March until this month. She states that unless the CARES Act is passed, she will lose her job in October. Pt also states she broke up with long term boyfriend of 7 years in July and started a new relationship shortly after. She states the new relationship is stressful and “toxic” because they “argue and break up every other day”. Pt also says she has “a lot on her plate” and takes on many new projects that she has not been able to work on since starting the new relationship. Patient admits to decreased appetite, recent 40 lb unintentional weight loss, and wanting to sleep a lot. Patient currently denies SI/HI and states “I was not trying to kill myself, I just wanted to sleep”, and “ I have a lot to live for”. Patient agrees to outpatient psychotherapy and antidepressant therapy once discharged. 

Collateral information received from patients ex-boyfriend. He reports that he has known the patient for over 7 years and she does not have history of harming herself or previous suicide attempts. He reports that the patient is stressed over their recent break up and also possibly losing her job in October. He reports that he still talks to patient everyday and knows she will not kill herself. 

Patient is calm, cooperative and goal oriented. Patient has normal speech and eye contact. Patient has full affect and in a euthymic mood. Patient denies SI/HI/VH/AH or intent to hurt self or others. Patient admits to cannabis use daily. Denies alcohol and other illicit drug use. Patient has adequate insight, impulse control and judgement. Patient is not psychotic and psychiatrically cleared for discharge. 

 

PMH

None

PSH

None

Medications

None

Allergies

Penicillin

Vitals

Temp 98.6

115/78

87

BMI 26.43

PE

WNL

MSE

Appearance: Patient is an average height and weight black female. She appeared to be in a clean hygienic state and her hospital gown was neat and clean.

Behavior and psychomotor activity: Patient is calm, not agitated or restless. She shows no signs of psychomotor slowing or retardation, or responding to internal stimuli.

Attitude: Patient established a good rapport with the examiner and was cooperative.

Alertness and cognition: Patient is alert throughout interview. 

Orientation: Patient is oriented to person,  place, and time.

Concentration and attention: Patient demonstrated satisfactory concentration and attention during interview. She gave relevant responses to questions.

Capacity to read and write: Patient has good reading/writing ability.

Abstract thinking: Patient is able to abstract concepts from a phase. 

Memory: Patient’s remote and recent memory is unimpaired. 

Intellectual functioning: Patient has average intellectual functioning and is consistent with her level of education and her occupational achievement (flight attendant).

Mood: Patient’s mood was euthymic but is worried about her job status.

Affect: Patient’s has a full affect.

Appropriateness: Patient’s mood and affect is consistent with her case. She did not exhibit labile emotions, angry outbursts, or uncontrollable crying.

Speech: Patient’s speech is fluent, normal in rate, volume and regular rhythm.

Eye contact: Patient made adequate eye contact.

Body movements: Patient did not show any signs of extremity tremors or tics.

Impulse control: Patient’s impulse control is impaired. She currently has no suicidal or homicidal ideations.

Judgement: Patient has no bizarre delusions, paranoia, auditory or visual hallucinations.

Insight: Patient has good insight into her psychiatric condition and is requesting outpatient psychiatric therapy and medication. She is aware she is overwhelmed and depressed.

 

Differential Diagnosis:

1. Adjustment disorder: patient presents with anxiety and depression that appeared within 3 months after the loss of her job, breakup with boyfriend, and stressful situations surrounding COVID. She also presented with suicidal thoughts and acted impulsively when she took extra cyclobenzaprine pills in order to “sleep for a long time”. Patients with adjustment disorder often present with no prior significant psychiatric history in the aftermath of a life event that has overwhelmed them. 
2. Major depression disorder: patient is presenting with a sad mood, excessive sleep, loss of interest in daily activities, suicidal thoughts, decreased appetite and weight loss. Although she is experiencing signs and symptoms of MDD, they have not persisted for 6-12 months.  
3. PTSD: patient is presenting with depressive symptoms, such as loss of interest in things she used to enjoy and impaired concentration that has persisted beyond 1 month after loss of her job, COVID, and breakup. However, this diagnosis is unlikely because she is not presenting 2 or more negative moods, flashbacks, or having distressing memories.
4. Generalized anxiety disorder: patient is presenting with excessive worry and anxiety over her job and relationships. She is easily fatigued and it has impaired her social and occupational function. However, these symptoms have not persisted over a 6 month period. 

Plan:

Discharge from CPEP unit

She is educated to abstain from illicit substance use

Start lexapro 10 mg PO 1 tab daily

F/u with outpatient psychiatrist/therapy  

 

H&P 2

CC: suicidal ideations and attempt 

HPI

15 y/o AA female, currently in 10th grade at Benjamin Cardozo high school, with no diagnosed psych or PMHx, domiciled with parents, BIBEMS- self activated, for reported suicide attempt. Pt states yesterday she was feeling very depressed, crying, numb, and wanted to kill herself. Pt states she went to the pharmacy to purchase a bottle of Aspirin. When she got home, pt states she had the pills in her hand but got scared and upset, prompting her to call 911. Pt admits to auditory hallucinations telling her to kill herself and calling her name, which has happened during prior attempt 1 year ago. Pt states she’s been depressed since the 6th grade due to family problems and school, but denies ever seeing a mental health professional or taking psych medications. Pt states she enjoys drawing and dancing but lately has felt a lack of interest in her hobbies. Pt currently denies SI/HI, AH/VH, intent to hurt self or others, however appeared to be sad, with depressed mood, poor eye contact, flat affect.    

Collateral information was previously obtained from patient’s mother. Writer attempted to call this morning multiple times, however no answer. 

Upon morning re-evaluation, pt states she is feeling better. Pt is alert and cooperative. She is soft spoken, with normal rate and increased latency. Pt has limited eye contact with head down and flat affect. Pt appears depressed, nervous, isolated and withdrawn throughout interview. Pt states she is open to outpatient psychotherapy upon discharge, however states that she does not trust herself if she goes home. Awaiting call back from mother for dispo planning, however due to patient’s recent behavior, anhedonia, depressive symptoms and inability to contract for safety, patient will benefit from inpatient psychiatric admission.

 

PMH/ PPH

None

 

Allergies

Peanuts

 

Review of Systems

Positive for anxiety and depression

Substance abuse: denies

 

PE

Vitals

121/72

Temp 98.3

Pulse 82

RR 18

O2 98% room air

 

PE

HEENT – wnl

Skin/ extremities – wnl

Cardio – wnl

Pulmonary – wnl

GI – wnl

 

MSE

Appearance: Patient is an average height and weight black female. She appeared to be in a clean hygienic state.

Behavior and psychomotor activity: Patient appears sad, anxious, and nervous. She shows no signs of psychomotor slowing or retardation, or responding to internal stimuli.

Attitude: Patient established a good rapport with the examiner and was cooperative.

Alertness and cognition: Patient is alert throughout interview. 

Orientation: Patient is oriented to person,  place, and time.

Concentration and attention: Patient demonstrated satisfactory concentration and attention during interview. She gave relevant responses to questions.

Capacity to read and write: Patient has good reading/writing ability.

Abstract thinking: Patient is able to abstract concepts from a phase. 

Memory: Patient’s remote and recent memory is unimpaired. 

Intellectual functioning: Patient has average intellectual functioning and is consistent with her level of education and her occupational achievement (flight attendant).

Mood: Patient’s mood was depressed, anxious and sad..

Affect: Patient has a flat affect.

Appropriateness: Patient’s mood and affect is consistent with her case. She did not exhibit labile emotions, angry outbursts, or uncontrollable crying.

Speech: Patient’s speech is fluent, and soft spoken.

Eye contact: Patient made avoidant eye contact.

Body movements: Patient did not show any signs of extremity tremors or tics.

Impulse control: Patient’s impulse control is impaired. She currently has no suicidal or homicidal ideations.

Judgement: Patient has poor judgment based on self-defeating/ endangering behavior.

Insight: Patient has good insight into her psychiatric condition and is requesting inpatient psychiatric therapy. She is aware she is depressed and requires treatment.

 

 

Assessment and Plan

15 y/o AA female, currently in 10th grade at Benjamin Cardozo highschool, with no diagnosed psych or PMHx, domiciled with parents BIBEMS- self activated, for suicide attempt today with Aspirin.

Pt is not psychiatrically stable, posing risk to self. Pt is not cleared for discharge, will need to remain in EELOS for pediatric psychiatrist in the morning. Plan discussed with mother who agrees and will return in the morning after pt is re-evaluated.

1:1 observation

Labs: CBC, CMP, THC, Alcohol level,  UA, urine toxicology, beta hCG

COVID 19 swab

Discuss with SW for inpatient transfer

Differential Diagnosis:

1. Dysthymic disorder (persistent depressive disorder): Persistent depressive disorder is a depressive mood disorder characterized by a chronic course and an early and insidious onset. Symptoms include a negative outlook on life, depressed mood, restlessness, anxiety, anhedonia, and a tendency to anticipate that future events will be negative. Symptoms occur most of the day for at least a year. This could be her diagnosis because she is mostly feeling depressed on most days and multiple episodes of suicidal ideations and attempts.
2. Major depression disorder: 5 of the following symptoms have to be present during the same 2 week period, which include depressed/ irritable mood, diminished interest or loss or interest in activities, significant weight change, sleep disturbance, psychomotor agitation, and fatigue or loss of energy.
3. Adjustment disorder: patients will have emotional or behavioral symptoms within 3 months of a specific stressor occurring in their life. Symptoms include depressed or sad mood, anxiety, or disturbance of conduct. This could have been her diagnosis because her parents are in the middle of a divorce, however her symptoms have been happening for years.
4. Generalized anxiety disorder: characterized by persistent and excessive worry about many things. Patients may anticipate disaster and be overly concerned about school, health, family and friends. This is unlikely because she is not having persistent anxiety and worry on most days.