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Chief Complaint Health Report
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Case study 1
Chief Complaint Health Report
Chief complaint: (patient own words) I need to get my medication fixed
History of present illness: 42- year old African American with history of schizophrenia and
anxiety. According to the present history, the patient had presented worsening mood, visual
hallucination and delusional thoughts .She was having weird with people whom she speaks to
that aren't there and pricking off her skin that does not exist.
Past psychiatric history: The patient was previously diagnosed with anxiety disorder and
schizophrenia. After showing signs of anxiety disorder and schizophrenia, she was admitted to
cedar crest x3 psychiatric hospital. In addition, she has been in ASH, Dallas facility, and green
acres. She was currently outpatient treatment with MHMR at Brazos valley.
Drug/ Alcohol abuse history: Denied tobacco and alcohol, history of marijuana,
methamphetamine use. However, she has been using marijuana continuously for two months.
Previously medication trials were denied because her history of suicide attempts or self-harm
behavior was dismissed. Medical History: cholecystectomy, hernia repair. The client had no
known allergies.
Social History: homeless, lives in temple, single, no children, completed college. Currently
employed as a pawnbroker. Family History: unknown. Current medication: Atility 10mg
Admitting diagnosis: schizophrenia, anxiety DO, substance induced psychotic DO,
Amphetamine use DO and Cannabis use DO. Initial plan of care and medication consent: the
patient was provided with information on the purpose of treatment. Haldol for psychosis to 25/50
mg, Cogentin for EPS to 1 mg and g Gabapentin for anxiety 300mg.
Estimated length of stay: 5-7 days
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Case study 2
Chief complaint: (patient own words) UTA
History of present illness: 30-year-old Hispanic male with a history of schizophrenia,
depression and anxiety. The client does not provide any information. He does not make any
sense.
Past psychiatric history: The patient was previously diagnosed with anxiety disorder,
depression and schizophrenia. Previous medication include; Risperdal, Zoloft.
Drug/ Alcohol abuse history: Unknown.
Medical History: Denied.
Social History: lives in Cedar Park with family, married with two children aged 10 and 14,
unemployed and no known religious affiliations.
Family History: unknown history of mental health conditions in the family.
Current medication: Risperdal 0.5mg PO BID for mood and Zoloft 150 mg PO daily for
depression.
Admitting diagnosis: schizophrenia spectrum and catatonia.
Initial plan of care and medication consent: the patient was provided with information on the
purpose of treatment. Increase Risperdal for Psychosis, Taper off Zoloft, add Ativan for
catatonia.
Estimated length of stay: 7-10 days
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Case study 3
Chief complaint: (patient own words) was feeling anxious and wanted to overdose on my
medications
History of present illness: 60-year-old African American with previous history of depression
and schizophrenia. Presented for worsening mood changes and decompensation. She has suicide
ideation and an overactive bladder. Not eating and sleeping well.
Past psychiatric history: The patient was previously diagnosed depression and schizophrenia.
She was admitted at Houston Psychiatric center. Previous medication include; Risperdal, Zoloft,
Paxil, Thorazin, Haldol, Risperdal, Geodon and Ativan.
Drug/ Alcohol abuse history: Denied.
Allergies: NKDA
Medical History: H/O stroke, overactive bladder, fractured pelvis and tubal ligation.
Social History: Lives in Fort Worth alone. Single, separated 30 years ago, unemployed and has
one daughter and three grandchildren.
Family History: unknown history of mental health, suicide ideation in the family.
Current medication: off medication.
Admitting diagnosis: MDD R/S, UTI, H/O stroke.
Initial plan of care and medication consent: the patient was provided with information on the
purpose of treatment. The patient should be locked up since she is violent and disruptive. Zoloft
125 mg daily PO for mood, Haldol 25 mg PO.
Estimated length of stay: 7-10 days
5
Case study 4
Chief Complaint: (In-patient own words) “I felt like I needed to get somewhere”.
History of present illness: 19 years old African American male was diagnosed with anxiety
disorder. Patient was presented in a delusional state of mind and reports that people are watching
him and possessing a risk of harming himself due to delusional behavior.
Past psychiatric history: The patient was previously diagnosed anxiety and schizophrenia.
Current outpatient treatment with MHMR at Brazos valley. No previous medication trials.
Drug/ Alcohol abuse history: Denied alcohol and cigarette smoking however, he reported
occasionally smoking marijuana.
Allergies: NKDA
Medical History: Deviated septum repair
Social History: From Austin. Lives with parents and younger brother (aged 13). Single and
never married. No children. Completed high school and college. Currently unemployed with no
previous military record. Denied religious affiliations.
Family History: unknown history of mental health, suicide ideation in the family.
Current medication: no known medication.
Admitting diagnosis: MDD R/S.
Initial plan of care and medication consent: 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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Case study 5
Chief Complaint: (In-patient own words) “the police brought me here”.
History of present illness: 33-year-old African American female with prior psychiatric history
of BPAD, anxiety, and PTSD. Presented for worsening mood and suicidal ideation. Reported
being off medication for the past week. Recently moved from San Antonio to Round Rock. Not
eating or sleeping well. Feels tense and experiences panic attacks. Excessive worries and cries a
lot. Easily annoyed.
Past psychiatric history: previous psychiatric hospitalization at Cedar Crest in 2014, Advent
BH in 0/21. Rock Springs in 2020 and GBHI in 2013. Previous medication include, Abilify,
Wellbutrin, Vistaril, Klopin, Minipress and Trazodone. Reported suicidal attempts, prior self-
harm was denied.
Drug/ Alcohol abuse history: uses vape for Tobacco. Denied cigarette smoking and marijuana
use.
Allergies: NKDA
Medical History: None reported
Social History: lives in Round Rock alone. Single with one daughter aged 6. Completed high
school and college. Currently employed as a waitress at Outback steakhouse. No prior military
service.
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: MRE depression, PTSD by Hx, Tobacco use DO-mild, anxiety DO.
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Initial plan of care and medication consent: start group therapy, place on Q 15 observations,
comfort meds PRN, added Wellbutrin for depression, Abilify for mood, Klopin PRN for severe
anxiety, and Minipress for PTSD.
Estimated length of stay: 3-5 days
8
Case study 6
Chief Complaint: (In-patient own words) “I need to get my medication fixed”.
History of present illness: Kiersten 14 years old was admitted with Acute case of depression,
SI, Suicidal plan. She sated becoming depressed in the last few weeks. She already started
think9ng suicide in last few days; she wanted to cut of overdose pills
Past psychiatric history: They include the GAD, ADHD in the pat help psych hospitalization of
depression med within herself in the past
Drug/ Alcohol abuse history: denies
Allergies: NKDA
Medical History: Asthma
Social History: She lives with her mother, sister, and grandparents. She is going to be ninth
grade in school. She denies abuse h/x. The boyfriend broke up with her 1-month period. She
denies legal issues
Family History: Grandparents’ depression
Current medication: Atility 10mg
Admitting diagnosis: GAD, BPD, ADHD, MDD
Initial plan of care and medication consent: Abilify for mood, Klopin PRN for depression
Estimated length of stay: 3-5 days
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Case study 7
Chief Complaint: (In-patient own words) “I was threatening myself I punched my brother
flying to choke my sister.”
History of present illness: Dasleesia, 13-year-old AAF was admitted to acute xxx of anger,
aggression, and homicide. She chocked his sister, hit her brother and thought about killing
herself with a knife.
Past psychiatric history: They include the GAD, ADHD in the pat help psych hospitalization of
depression med within herself in the past
Drug/ Alcohol abuse history: denies
Allergies: NKDA
Medical History: Asthma
Social History: She lives with her mother and two brother and three sisters at casket height , TX.
The patients separated wen shew was 3 years old. She is going to the 7
th
grade in school this year
she denies abuse. She denies legal issues
Family History: none reported
Current medication: Atility 10mg
Admitting diagnosis: DMDD, ADHD, sibling deletional problems, ODD
Initial plan of care and medication consent: 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: 6-7 days
10
Case study 8
Chief Complaint: (In-patient own words) “I tried to overdose yesterday.”
History of present illness: Kaleb 14 years old was admitted to acute case of overdose on
Tylenol, and anxiety. He took 10 mg to 12 mg of Tylenol with the antibiotic to kill himself.
Past psychiatric history: No psych hospitalization of depression on few months not talking of
depression or anxiety with any psychiatrist
Drug/ Alcohol abuse history: denies. Smokes once every week.
Allergies: NKDA
Medical History: Asthma
Social History: He lives with his dad, stepmother at China Spring, TX. His patients developed
before he was born. He is going college this year he believed step dad used to abuse him in the
past. He denies legal issues
Family History: none reported
Current medication: Atility 10mg
Admitting diagnosis: MDD, SSE out of PF
Initial plan of care and medication consent: the patient was provided with information on the
purpose of treatment. Admit in Unit 3. Zoloft 125 mg daily PO for mood, Haldol 25 mg PO.
Estimated length of stay: 6-7 days
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Case study 9
Chief Complaint: (In-patient own words) “I was just having suicidal thoughts.”
History of present illness: Rebbie 14 years old was admitted to acute case of suicidal ideation,
depression and anxiety. She said having suicidal thoughts on and off for a while. However, it
started to become worse lately for a couple of weeks period. She was feeling sad, helpless for
losing her grandmother and son. She got divorced.
Past psychiatric history: Multiple psych hospitalization for suicidal attempts did overdose.
DMDD in the past
Drug/ Alcohol abuse history: Denies
Allergies: NKDA
Medical History: None reported
Social History: He lives with his dad, stepmother at China Spring, TX. His patients developed
before he was born. He is going college this year he believed step dad used to abuse him in the
past. He denies legal issues
Family History: none reported
Current medication: none reported
Admitting diagnosis: GAD, BPD, MDD, R.S.E out PE, Trauma and stress
Initial plan of care and medication consent: Encourage individual therapy of CBT. The patient
was provided with information on the purpose of treatment. Admit in Unit 1. Medication atility
to 5mg
Estimated length of stay: 6-7 days
12
Case study 10
Chief Complaint: (In-patient own words) “I started smoking marijuana. My mom caught me .
She sent me to hospital.”
History of present illness: Muhammed, 15 yrs old was admitted of institutional overdose and
drugs use. No states he took 6-7 tabs of Seroquel and clonidine to get high on 06/3/21. He stated
he did overdose not to kill himself the was having a lot of time this seeking behavioral , He was
smoking marijuana of 2yrs period He was feeling sad of her mom being sick. He denies account
hallucination
Past psychiatric history: Psych hospitalization of psychosis, drug use, level suicidal, attempt in
past DMDD, GAD, substance abuse in the past
Drug/ Alcohol abuse history: Alcohol use
Allergies: NKDA
Medical History: None reported
Social History: none reported
Family History: none reported
Current medication: none reported
Admitting diagnosis: GAD, depression.
Initial plan of care and medication consent: Encourage individual therapy of CBT. The patient
was provided with information on the purpose of treatment. Admit in Unit 1. Zoloft 125 mg daily
PO for mood
Estimated length of stay: 6-7 days
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