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Chief Complaint Health Report
Student's Name
University
Course
Professor
Date
2
Chief Complaint Health Report
Chief complaint
I need to get my mediation fixed
History of present illness
HISTORY OF PRESENT ILLNESS (To include onset of illness and circumstances leading to
admission)
27-year-old African American male with a prior psychiatric history of Mood disorder who
presented involuntary.
Presented on EDO on 08/18/21. Reported “….reported having command hallucinations telling
him to kill himself and others. Jonathan reports having suicidal thoughts to hang or cut himself.
He reports having suicidal thoughts to shoot or cut someone. He was brought in from jail. He
was agitated. Reported hearing voices telling him to kill others. Has been increasingly agitated.
He was released from prison last year after spending 6 years behind bars. Refused vitals in
admission.
Presently is a limited historian. Unable to provide a reliable history of present illness. Unable to
determine onset at this time. Feels sad and depressed. Poor self-image. Guilt issues. Easily
angered. Impulsive mood. Denied access to firearms.
Past psychiatric history
(To include prior precipitating factors, past diagnoses, course of treatment, past
hospitalization or harm attempts.):
Previously diagnosed include Mood D/O. Previous psychiatric hospitalizations at
Skyview while in prison. Currently outpatient treatment with BET. Previous
medication trials include Vryalar, Ability, and Trazod one. Prior history of suicide
attempts reported or self-harm behavior was unknown.
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Drug/ Alcohol abuse history: (To include drugs of choice, patterns of use, treatment history.)
Smokes tobacco occasionally. Drinks alcohol on occasion. History of cannabis use, last use was unknown.
Medical History (To include chronic/acute illness, current medical treatment, past surgical procedures,
recent hospitalization):
Denied. Exploratory surgery after being stabbed.
Social History: (To include educational level, vocational/occupational/employment history/status,
Lives relations ships and supports).
Lives in Caldwell with his mom. Single, never married. No children. Completed HS. Currently
unemployed. Prior military service was denied. Prior legal issues for assault, robbery, released in
2020. No current charges Prior sexual and emotional abuse was reported. Denied religious
affiliation.
Family History (to include any psychiatric and or substance history within the family).
Unknown mental health, chemical dependency).
Grandparents’ depression
Current medication
Denied
Admitting diagnosis
BPAD-Unspecified type,
ADHD by hx
Antisocial PD
Initial plan of care and medication consent
Proposed medication and dosage range and frequency, 2) the purpose of the treatment 3)
common short and long term side effects of the proposed medication including contraindications
and clinically significant interactions, with other medications
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1. Admit to inpatient-Unit IV-on EDO
2. Place on Q15 observations
3. Routine laboratory studies
4. Encourage group therapy
5. Comfort MEDs PRN
6. Start medications
7. Add Risperdal, Depakote for mood, Clonidine for Impulsivity
Estimated length of stay
5-7 days
Initial discharge plan
Home
Chief complaint
I was overwhelmed; they are asking too much stuff to do
History of present illness
Jessica, 13-year-old female admitted to the acute care, put a rope around his neck to kill himself
and planned to hang herself. She has been thinking about suicide for the last two days.
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Past psychiatric history
GAD in the past
Drug/ Alcohol abuse history:
Denies
Medical History
Asthma, overweight
Social History:
She lives with her mother and cousin, cousin’s husband, daughter at Killin, Tx. She denies abuse; she is
in the 8
th
grade of the school.
Family History
Mother depression, stepfather killed himself.
Current medication
Buspal 1 mg
Admitting diagnosis
MDD, GAD
Initial plan of care and medication consent
Admit unit 3, medication for patient,
Estimated length of stay
5-7 days
Initial discharge plan
Home
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Chief complaint
A 15 year old was admitted to the acute care for PnP with depressed mood, and aggressive
behaviors.
History of present illness
Elliot, 15 years old was admitted to acute care for depression, suicide ideation and anxiety. His
step dad died last year. He is in the 7
th
grade at school.
Past psychiatric history: The patient was previously diagnosed depression. He was admitted at
Houston Psychiatric center. Previous medication include; Risperdal, Zoloft, Paxil,.
Drug/ Alcohol abuse history: Denied.
Allergies: NKDA
Medical History: H/O stroke, overactive bladder, fractured pelvis and tubal ligation.
Social History: he lives with his mother and siblings, at Chine spring, TX. He gets along with
mother. denies abuse.
Family History: unknown history of mental health, suicide ideation in the family.
Current medication: Zoloft 50 mg daily.
Admitting diagnosis: MDD, GAD
Initial plan of care and medication consent:
Admit in unit 3, increase Zoloft dosage to 100mg daily.
Estimated length of stay: 7-10 days
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Chief Complaint: (In-patient own words) “I felt like killing myself”.
History of present illness: Leone is a 17 year old Hispanic male was admitted to acute care for
depression, and suicidal attempt, he took codeine to kill himself, he was confused and appeared
talking to himself.
Past psychiatric history: he was hospitalized in the past with Bipolar disorder, and suicidal
attempt
Drug/ Alcohol abuse history: he reports doing all kinds of drugs in the past, marijuana, opioid
in the past
Allergies: NKDA
Medical History: HIV, obesity, knee surgery
Social History: He lives with his father, denies any abuse
Family History: Bipolar disoder in the family.
Current medication: ART.
Admitting diagnosis: MDD R/S.
Initial plan of care and medication consent: admit in unit 3, the patient was provided with
information on the purpose of treatment. Zoloft 125 mg daily PO for mood, Haldol 25 mg PO.
Estimated length of stay: 7-10 days
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Chief Complaint: (In-patient own words) “I was going to commit suicide, I was going to
overdose, I told my friend about it”.
History of present illness: Reagan, a 13-year-old female, was admitted to acute care with
auditory and visual hallucination and suicidal plan. She planned to take all her medication and
overdose on herself.
Past psychiatric history: MDD, Borderline PD, several abuse, depression in the past.
Drug/ Alcohol abuse history: uses vape for Tobacco. Denied cigarette smoking and marijuana
use.
Allergies: NKDA
Medical History: Hypothyroidism,
Social History: she lives with his mother and 11-year-old brother. She is in the 8
th
grade in
school.
Family History: Denied substance use in the family, denied history of mental illness in the
family.
Current medication: off med for a week
Admitting diagnosis: MDD, PTSD by Hx,
Initial plan of care and medication consent: admit in unit 3, Ablify 10 mg
Estimated length of stay: 3-5 days
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