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Chief Complaint Health Report
Chief complaint: suicidal thoughts
History of present illness: Danijy (wanted to be referred to as DJ) was admitted to the acute
unit for suicide thoughts. She had plans of cutting herself. She had feelings of sadness, worthless
and lost interests in activities that were enjoyable to her.
Past psychiatric history: overdose of pills, suicidal ideation and thoughts of harming herself in
the past. Has been previously admitted to a psychiatric hospital for depression, MDD and
suicidal ideation.
Drug/ Alcohol abuse history: denies
Medical History: Asthma, seasonal environmental allergies
Surgery: none reported
Social History: she has been staying at the emergency shelter for 3 weeks. Her father is serving
prison sentence for assault. She is going to the 9
th
grade in school.
Family History: her father used drugs. Her grandmother on the other hand contemplated suicide
in the past.
Current medication: fluticasone 25 mg, Abilify 10 mg daily,
Admitting diagnosis: PTSD, seasonal allergies, Asthma,
Initial plan of care
The patient was provided with adequate information in regard to the entire medical procedures
and plans. Admit in the 3
rd
unit, Administer: Atility 2.5 mg, Zoloft 50 mg taken on daily basis to
control depression
Estimated length of stay
6-8 days
Chief complaint: I tried killing myself by ingesting a bleaching agent yesterday. i have always
had trouble at home.
History of present illness: Eli, a 15-year-old male was admitted to the acute care for suicidal
attempt by ingesting Lysol and bleaching agent. He took three cups of the mixture to eliminate
himself. He says that family conflict triggered this action.
Past psychiatric history: no psychiatric hospitalization in the past.
Drug/ Alcohol abuse history: Used vapes a month ago. Denies using any form of drugs.
Medical History: athletics foot, seasonal allergy
Surgery: denies
Social History: he lives with his parents and one sister at Clifton, Texas. He is going to be 8
th
grade at school. He denies any form of abusive relationship. He denies any legal issues.
Family History: Denies
Current medication: Triamcinolone, topical chew
Admitting diagnosis: unspecified MDD, ODD, GAD, several abuse.
Initial plan of care
The patient was provided with adequate information in regard to the entire medical procedures
and plans. Admit in the 3
rd
unit, Administer: Wellbutrin 100 mg taken daily, continue on for
allergies management.
Estimated length of stay
6-7 days
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