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Chief Complaint Health Report
Student's Name
University
Course
Professor
Date
2
Chief Complaint Health Report
Chief complaint: whenever I ran away from home, I called police for assistance but they
insisted that I should go to hospital.
History of present illness: Radisson is a 16-year-old female admitted in acute care for suicide
ideation, suicidal plan and depression. She ran away from home on Sunday night after her dad
yelled at her. She threatened to jump over from their balcony.
Past psychiatric history:
Has been through physical and emotional abuse in the past. Attempted suicide twice and was
hospitalized in psychiatric hospital in the past.
Drug/ Alcohol abuse history: none was reported
Medical History: admitted to psychiatric hospital, diagnosed with depression
Surgery: none reported
Social History: she stays with her father, 3 sisters and one brother in temple road, Texas. She is
in her 11
th
grade and believes her dad hates her by judging through his actions.
Family History: Grandparents’ depression
Current medication: none
Admitting diagnosis: unspecified MDD, emotional and physical abuse, ODD
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
6-7 days
3
Chief complaint: I ran away without a reason then called the cops
History of present illness: Bailey is a 14-year-old girl who is admitted to the acute care for
exhibiting suicidal behaviors, depression and risk taking mannerism. Her friends send messages
to the cops that she had bad intentions of self-harm. She disappeared from her home three days
ago.
Past psychiatric history: previously admitted to a mental health hospital, thoughts of killing
herself. MDD, GAD
Drug/ Alcohol abuse history: uses nicotine, consumes alcohol and smokes marijuana.
Medical History: broken ankle,
Surgery: denies
Social History: lives with her mother in Texas, she will be moving to 9
th
grade this year. Her 18-
year-old girlfriend abused her sexually.
Family History: none reported by the client
Current medication: Hexatone 100 mg,
Admitting diagnosis: sexual abuse victim, GERD, MDD
Initial plan of care
Inform the patient of the care plan, Unit 3 admission, Zoloft 100 mg for depression,
Estimated length of stay
5-7 days
4
Chief complaint: I overdosed on over the counter pills
History of present illness: Valencia is a Hispanic female-aged 14 years old admitted for
intentional pill overdose on Zoloft and suicidal thoughts and attempts. She overdose on a record
17 pills of Zoloft 100 mg to eliminate herself. Her friends through hostile text messages have
harassed her.
Past psychiatric history: no record of mental health facility hospitalization, school bullying and
harassment.
Drug/ Alcohol abuse history: none
Medical History: overdose on Zoloft
Surgery: denies
Social History: she lives with her parents and one sister in Texas. End of this year, she will be
attending 8
th
grade in school. Bullying from friends and classmates.
Family History: reports none
Current medication: none reported except Zoloft
Admitting diagnosis: anxiety, overdose on Zoloft, MDD
Initial plan of care
Admit patient in unit 3; administer medications as advised, oxazepam (Serax) 45 mg taken each
day.
Estimated length of stay
5-7 days
5
Chief complaint: started thoughts of harming myself.
History of present illness: presented for worsening mood, plans to strangle himself and commit
suicide. Reports poor personal self-image. She started a fire near where she lives, reported
having hallucinations and flashbacks during the day.
Past psychiatric history: ADHD, MDD, ODD, hospitalized at Cedar Groove Health mental
facility.
Drug/ Alcohol abuse history: none
Medical History: none
Surgery: denies
Social History: lives in Hewitt with her dad, mom, brother aged 16, sister aged 11 years, brother
aged 11, she will be moving to the 9
th
grade.
Family History: reports none
Current medication: Atarax 25 mg taken on daily basis, Concerta 25 mg taken daily, clonidine
0.02 mg taken daily.
Admitting diagnosis: MDD, ADHD, ODD and a victim of sexual abuse.
Initial plan of care
Admit to unit 111, routine labs tests and admission, continue Concerta as prescribed.
Estimated length of stay
5-7 days
6
Chief complaint: started thoughts of harming myself.
History of present illness: Natalie a 13 year old admitted for suicidal thoughts and self-
harming characteristics. She started harming herself by cutting since last summer.
Past psychiatric history: auditory hallucination was hospitalized last year in a mental health
facility.
Drug/ Alcohol abuse history: none
Medical History: none
Surgery: denies
Social History: She lives with her brother, stepmother in Gatesville, TX. She also has four other
siblings. She will be attending 8
th
grade this year.
Family History: mother died of HLH disorder last 4 years.
Current medication: none
Admitting diagnosis: MDD, ADHD,
Initial plan of care
Admit in unit 3, Zoloft 50 mg taken on a daily basis, Abilify 2.5 mg
Estimated length of stay
5-7 days
7
Chief complaint: I have been battling anxiety for years now.
History of present illness: Sienna is a 14-year-old girl admitted for depression, anxiety and
suicide ideation. She was feeling sad, hopeless and disillusioned. She has no record of previous
treatment plan.
Past psychiatric history: hospitalized for depression, anxiety in the past, loss of appetite.
Drug/ Alcohol abuse history: none
Medical History: none
Surgery: denies
Social History: she lives with her mother, one sister and her brother in-law. Her biological
parents divorced six years ago. She is going to the 9
th
grade in school.
Family History: her oldest sister was diagnosed and hospitalized for depression and anxiety
disorder.
Current medication: none
Admitting diagnosis: MDD, GERD, child conflict.
Initial plan of care
Admit in unit 3, Zoloft 25 mg taken on a daily basis,
Estimated length of stay
5-7 days
8
Chief complaint: I just want to die by hanging myself; I do not like my body appearance,
History of present illness: Jessica is a 14-year-old Hispanic female admitted for depression,
self-harm and suicidal ideation. She appears sad and very hopeless. She has bad plans of hanging
ad killing herself.
Past psychiatric history: she has a previous hospitalization for depression. She checked for
psychotherapy.
Drug/ Alcohol abuse history: none
Medical History: reports asthma, eczema
Surgery: denies
Social History: she stays with her mother and three sisters, her father died 4 years ago, she does
not like her body looks and sees no reason to live again. She is in the 9
th
grade.
Family History: father died of depression, her older sister suffers from depression.
Current medication: Abilfy 5 mg taken daily,
Admitting diagnosis: GAD, gender dysphoria, MDD
Initial plan of care
Admit in unit 3, Zoloft 25 mg taken on a daily basis,
Estimated length of stay
5-7 days
9
Chief complaint: I have been trying to overdose. I going through a lot of things in my life.
History of present illness: Mitchell is a 17-year-old girl admitted to acute case with overdose on
prescribed medicine and severe anxiety. She appeared sick and overwhelmed. She took 15 tabs
of Ibuphlofew to harm herself.
Past psychiatric History: none she reported never tried to kill herself in the past.
Drug/ alcohol abuse history: none
Medical history: Overdose on Ibuphlofew
Surgery: denies
Allergies: None
Social History: she lives with her both biological parents, two sisters, one brother and their
grandfather. She will be attending her 8
th
grade end of this year.
Family History: none reported and discussed.
Admitting diagnosis: MDD, anxiety
Initial care of plan: Zoloft 25 mg daily
Estimated length of stay
5-7 days
10
Chief complaint: I try as much as possible to stay away from home. I often indulge in
marijuana.
History of present illness: Mercy 16 year old was brought to acute care with depression and risk
taking habits. She has had suicide ideation and intention to harm herself. Her grandparent was
not happy that she spends very little time at home and most of it with her boyfriend. She
threatened to commit suicide.
Past psychiatric History: she has been admitted multiple times at mental health facility in the
past. She was diagnosed with Bipolar disorder in the past.
Drug/ alcohol abuse history: uses Marijuana daily, no alcohol
Medical History: reportedly healthy
Surgery: denies
Allergies: she is allergic to Fluxomine,
Admitting diagnosis: Bipolar disorders, ODD, GAD
Initial plan of care: Cubebin to 0.5 mg PO B2D, Vistalis 20 mg PO for anxiety
Estimated length of stay:
6-7 days
11
Chief complaint: attempted suicide
History of present illness: Trezia 17 years old was admitted to acute case for depression, self-
harm and suicide ideation. She tried killing herself by strapping a belt around her neck. She
appeared very sad and hopeless.
Past psychiatric history: exhibited risky behavior such as self-harm,
Drug Alcohol abuse history: reported none
Medical history: Asthma
Surgery: none
Admitting diagnosis: Bipolar, ADHD
Initial plan of care: Dlithium to 300 mg PO B2D of mood disorders
Zoloft 50 mg PO daily for depression
Estimated Length of stay
5 to 7 days
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