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Chief Complaint Health Report
Student's Name
University
Course
Professor
Date
2
Case scenario 1
Chief Complaint Health Report
Chief complaint
I was to go for a long-term facility. I was admitted to a psychiatric hospital. Am not ready to go
back there.
HPI: Bianca, a 13-year-old female was admitted to acute care for SI, SIB and depression. She
was just discharged from Pesinantes Gasland last Frida. She has ongoing SI this Saturday. She
walked into her grandmother’s house holding a pair of scissors and started cutting herself.
Past psychiatric history:
History of MDD in the past. Just currently discharged from Pesinantes Gasland hospital.
Drug/ Alcohol abuse history: Denied
Medical History: Acne
Surgery - Denies
Social History
She lives with her mother, stepdad and three siblings in Tx. She is in 8
th
Grade at school. She
denies legal issues. Her mom abused her in the past.
Family History
Mother suffered from depression I the past. She cut herself.
Current medication
Abilify
Hydroxyzine
Doses unknown
3
Admitting diagnosis
GAD, MDD, emotional abuse victim,
Initial plan of care and medication consent
Cymbalta to 30 mg daily
Admit in unit 3
Estimated length of stay
6-7 days
4
Case scenario 2
Chief complaint
None stated
HPI: Presented for worsening mood. Plans to kill himself with a gun. Also aggressive towards
his grandmother. He has access to firearms; he fears that he could harm his grandmother. Feels
sad because he got legal charges. He got decreased interest in daily activities. He easily loses his
temper and ends up destroying properties.
Past Psychiatric History
GAD, MDD, PTSD, ADHD, denies SI and SIB.
Drug/Alcohol abuse
Denies the use of ETOH.
Medical History
Healthy
Social History
Lives in Temple, Tx with grandmother. In possession of firearms. Dropped out of school in 9
th
grade.
Family history
Mother in jail. Father unknown
Current medications
Lexapro 10 mg daily
Trazadone 100 mg daily BID
Admitting diagnosis
MDD,
5
Conduct disorder
Anti-social personality disorder
TOB use disorder/mild
PTSD
Initial plan of care and medication
Admit patient in unit 3, comfort meds PRN, Amantadine for THC, Wellbutrin for depression,
encourage group therapy.
Estimated length of stay
6 to 7 days
6
Case scenario 3
Chief Complaint
Nothing going on, suddenly I want to cut myself I do not know why
History of present Illness
Herley, a 15-year-old girl was admitted to acute care for SI, SIB and depression. She thought
about suicide for 5 years. She cut herself a wanted to commit suicide 2 days ago. She was
constantly feeling hopeless.
Drug/Alcohol Abuse History
Cigarettes, nicotine and usually drinks wine.
Medical history
Restless syndrome,
Social History
He lives with his mother at Waco Tx. His parents separated. Father is out of the picture. He is in
9
th
grade at school. sister has depression.
Admitting diagnosis
MDD, PTSD, SSE out of PF
Initial plan of care and medication consent
Admit in Unit 3
Abilify 2.5 mg daily.
Prozac 30 mg daily
Estimated length of stay
6 to 7 days
7
Case scenario 4
Chief complaint
I just need some help; you know I was framed for this.
History of the present illness
Nathan, a 17-year-old male was admitted to acute care for psychotic episodes. He was showing
disillusion and paranoid behavior. He threw his helmet down and told his coach that something
bad was going to happen. He was also seen yelling at his coach and fellow players.
Past psychiatric history
Hospitalization in the past.
Zoloft in the past for depression
No past psychiatric appointment
Drug/ Alcohol abuse History
Denies
Medical History
Surgery wisdom tooth extraction
Social History
He lives with his parents and denies any childhood physical or emotional abuse. His had
depression issues with drugs related problems.
Allergies: NKDA
Current medications: Zoloft 100 mg daily
Admitting diagnosis
GAD
MDD, R.S.E out PE
8
Initial plan of care
Admit in unit 1
Continue Zoloft 100 mg daily
9
Case scenario 5
Chief Complaint
I need help for my anger problems
History of present Illness
Isaiah a 7 year old was admitted to acute care for increased episodes of anger, aggression and
severally acting out behaviors. He talked with people not there.
Past psychiatric History
GAD, MDD, ADHD, past physical abuse victim, no psychiatric hospitalization.
Drug/ Alcohol Abuse History
Denies
Medical History
Seasonal allergy
Social history: he lives with his adoptive parents and brother. He was emotionally and sexually
abused.
Surgery: none
Admitting diagnosis
MDD R.S.R out PF
Trauma and stress related disorders
Initial plan of care and medication consent
Agility 5mg PO B2D
Estimated length of stay
6 to 7 days
10
Case scenario 6
Chief Complaint
My brother handed me a toy gun, I pulled the trigger towards my mum.
History of present Illness
I need to change my attitude. Her biological father died in 2016. He was close to her mother’s
boyfriend but he died in 2020 because of covid. Not sleeping and eating well. Struggling in
school not turning in his assignments.
Past psychiatric History
Hanging herself last year, 2 times OD in the past, one time IP psych hospitalization. August last
year depression DMDD in past
Drug/ Alcohol Abuse History
Denies
Medical History:
Tripletail 10 mg daily.
Social history: Lives in Waco with mum and brother. 9
th
grade, failing English and algebra
classes.
Admitting diagnosis
MDD, seasonal allergy, asthma, ADHD, bereavement
Initial plan of care and medication consent
Admit unit 3
Encourage group therapy
Estimated length of stay
6 to 7 days
11
Case scenario 7
Chief Complaint
Because of suicidal plans
History of present Illness
Kailye a 15 year old was admitted to acute care for suicidal ideation, plans and depression. She
said she called 911 for suicidal plans and safety concerns. She was thinking on overdosing and
killing herself.
Past psychiatric History
History of cutting herself, harming herself and overdosing. Hospitalized twice for psychiatric
issues. MDD, GAD
Drug/ Alcohol Abuse History
Smokes weed twice a week
Smokes cigarettes
Medical History: Covid 19 +ve, Zoloft
Social history: she lives with his grandparent in Palestine, Tx. She is I 10
th
grade at school. She
indicated that her grandparents were abusive in the past.
Admitting diagnosis
MDD, GAD
Initial plan of care and medication consent
Admit in unit 3, Zoloft 1000 mg daily
Estimated length of stay
6 to 7 days
12
Case scenario 8
Chief Complaint
Because I was punching someone in the face, foster brother Erick punched me in the stomach.
History of present Illness
Nicholas a 7 year old was admitted to acute care for anger issues and aggression and being
violent with others. He was placed under foster care for a month. He was becoming violent to
friends and family.
Past psychiatric History
Depression, MDD, ODD
Drug/ Alcohol Abuse History
Denies
Medical History
Healthy
Social history: lives with foster family at Abiverline, TX. He is in 2
nd
grade at school.
Admitting diagnosis
Depression, MDD, ODD
Initial plan of care and medication consent
Admit in unit 3,
Prozac 100 mg daily.
Estimated length of stay
6 to 7 days
13
Case scenario 9
Chief Complaint
I was stressed, a lot of things going through my life.
History of present Illness
Sophia is 15-year-old Hispanic female admitted to acute care for depression, suicidal ideation
and suicide attempt. She was stressed about school.
Past psychiatric History
Hanging herself last year , 2 times OD in the past , one time IP psych hospitalization. August last
year xx depression DMDD in past
Drug/ Alcohol Abuse History
Denies
Medical History
Over weight
Asthma
Admitting diagnosis
MDD R.S.R out PF
Overweight
Trauma and stress related disorders
Initial plan of care and medication consent
Admit in unit 3, Agility 5mg PO B2D
Estimated length of stay
6 to 7 days
14
Case scenario 10
Chief Complaint
I collected my pills to overdose. My mum yelled at us with no reason
History of present Illness
Madison 15 years old was admitted to acute case of depression, suicidal ideation and suicidal
plan. She was thinking overdosing on pills. This is time when her mother died last year
Past psychiatric History
Hanging herself last year, 2 times OD in the past , one time IP psych hospitalization. August last
year 2019 depression DMDD in past
Drug/ Alcohol Abuse History
Denies
Medical History
Over weight
Asthma
Admitting diagnosis
MDD R.S.R out PF
Initial plan of care and medication consent
Admit in unit 3, Agility 5mg PO
Estimated length of stay
6 to 7 days
15
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