CHIEF COMPLAINT: "I got a lot of stress and I have suicidal thoughts."
HISTORY OF PRESENT ILLNESS: Male patient had been seeing his primary care physician for anxiety and depression since 2001. This began with job related stress and he was a supervisor and was on 24-hour call. The patient became increasingly depressed and began isolating and staying in bed on his day off. He was also pastoring a church which he gave up after he was unable to focus on church matters. In addition, he co-signed notes for two of his sons for cars but they did not make payments and he eventually had to file Chapter 7 bankruptcy. The patient has been on disability since July of 2001 for "mental reasons." On this day of admission, he received a call from the IRS saying that he owed them 12,000 dollars on taxes related to his disability income. He was on short-term disability for 26 weeks and now is on permanent disability. In addition, the patient's wife is bipolar and is having psychiatric treatment presently and she has good and bad days throughout the week. The patient has depressive symptoms of crying, insomnia, anorexia with recent 20-pound weight loss, decreased concentration, psychomotor retardation, suicidal ideation with plan. When the IRS told him he owed them money, he told the woman who called to wait and he was going to get his shotgun and she would hear him make his payment. In addition, the patient has auditory hallucinations and hear vague voices talking to him . He also will hear his wife call him when she Is not present. At the present time, the patient has been taking Wellbutrin 150 milligrams daily, Lexapro 20 milligrams daily, and Xanax 1 milligram three times a day. He also uses a Combivent inhaler. He has been to the emergency room on several occasions for panic and anxiety attacks and he was treated symptomatically and released.
PAST PSYCHIATRIC HISTORY: Is as noted above. There is no evidence of physical, emotional or sexual abuse as a child and there is no evidence of substance abuse. He denies any family history of emotional illness.
MEDICAL AND SURGICAL HISTORY: At work the patient was moving a chlorine tank which ruptured and he inhaled chlorine gas and was hospitalized for a week. He also has asthma and sinus problems.
FAMILY HISTORY: His wife as previously noted has bipolar disorder. One son has problems with anger management and is currently disabled because of this.
SOCIAL HISTORY: The patient has a high school education. He worked for 38 years before he was disabled. He feels that he gets along well with people. His marriage is solid but his wife's mental problems which have been going on for five for seven years causes him stress.
REVIEW OF SYSTEMS: HEENT - Non-contributory. Cardiorespiratory - Patient has shortness of breath. Gastrointestinal - Non-contributory. Genitourinary- Non-contributory. Musculoskeletal - Non-contributory.
PHYSICAL EXAMIATION: Is per emergency room physician.
RECTAL AND GENITALIA: Deferred to local physician.
NEUROLOGIC: See neuro flow sheet.
MENTAL STATUS EXAM: Patient is a will nourished, well developed white man in moderate to marked distress. He is tearful during the initial interview. His mood is depressed and his affect is appropriate for the situation. Stream of mental activity is unremarkable, there is no evidence of delusions or ideas of reference. He does have auditory hallucinations. He appears to be of average intellectual functioning. His memory is good for remote and recent events. His general knowledge Is good. Insight and judgment are fair.
INVENTORY OF STRENGTHS AND WEAKNESSES: Patient's primary strength is his recognition of illness and willingness to accept help. Weaknesses include difficulty in dealing with stressful situations and difficulty in controlling impulses at times.
DIAGNOSIS:
AXIS I
1. Major depressive illness, recurrent with suicidal ideation and plan and psychotic features.
2. Panic/Anxiety by history.
AXIS 11
1. No diagnosis.
AXIS III
1. Asthma .
2. Sinus problems.
3. History of chloride gas poisoning.
AXIS IV
1. Psychosocial stressors; primary support.
2. Finances.
3. Wife's illness
AXIS V
1. Current GAP is 28, highest GAF past year 60.
LABORATORY TESTS: Routine laboratory work will be done and any abnormalities will be documented and addressed.
TREATMENT PLAN: Patient will have individual and group therapy. His Wellbutrin will be increased and he will be started on low doses of Seroquei which will be increased if psychotic symptoms are not abated. We will also advise him to get legal help.
PROBLEM SUMMARIES AND RECOMMENDATIONS; This 58-year-old married white male is admitted for treatment of depression with suicidal Ideation and psychotic features secondary to multiple stressors as noted in history and physical.
PROGNOSIS: Fair to good.
ESTIMATED LENGTH OF STAY: 7 to 10 days
DISCHARGE CRITERIA: Resolution of depression, suicidal ideation and auditory hallucinations, follow-up treatment plan in place.
HISTORY OF PRESENT ILLNESS: Male patient had been seeing his primary care physician for anxiety and depression since 2001. This began with job related stress and he was a supervisor and was on 24-hour call. The patient became increasingly depressed and began isolating and staying in bed on his day off. He was also pastoring a church which he gave up after he was unable to focus on church matters. In addition, he co-signed notes for two of his sons for cars but they did not make payments and he eventually had to file Chapter 7 bankruptcy. The patient has been on disability since July of 2001 for "mental reasons." On this day of admission, he received a call from the IRS saying that he owed them 12,000 dollars on taxes related to his disability income. He was on short-term disability for 26 weeks and now is on permanent disability. In addition, the patient's wife is bipolar and is having psychiatric treatment presently and she has good and bad days throughout the week. The patient has depressive symptoms of crying, insomnia, anorexia with recent 20-pound weight loss, decreased concentration, psychomotor retardation, suicidal ideation with plan. When the IRS told him he owed them money, he told the woman who called to wait and he was going to get his shotgun and she would hear him make his payment. In addition, the patient has auditory hallucinations and hear vague voices talking to him . He also will hear his wife call him when she Is not present. At the present time, the patient has been taking Wellbutrin 150 milligrams daily, Lexapro 20 milligrams daily, and Xanax 1 milligram three times a day. He also uses a Combivent inhaler. He has been to the emergency room on several occasions for panic and anxiety attacks and he was treated symptomatically and released.
PAST PSYCHIATRIC HISTORY: Is as noted above. There is no evidence of physical, emotional or sexual abuse as a child and there is no evidence of substance abuse. He denies any family history of emotional illness.
MEDICAL AND SURGICAL HISTORY: At work the patient was moving a chlorine tank which ruptured and he inhaled chlorine gas and was hospitalized for a week. He also has asthma and sinus problems.
FAMILY HISTORY: His wife as previously noted has bipolar disorder. One son has problems with anger management and is currently disabled because of this.
SOCIAL HISTORY: The patient has a high school education. He worked for 38 years before he was disabled. He feels that he gets along well with people. His marriage is solid but his wife's mental problems which have been going on for five for seven years causes him stress.
REVIEW OF SYSTEMS: HEENT - Non-contributory. Cardiorespiratory - Patient has shortness of breath. Gastrointestinal - Non-contributory. Genitourinary- Non-contributory. Musculoskeletal - Non-contributory.
PHYSICAL EXAMIATION: Is per emergency room physician.
RECTAL AND GENITALIA: Deferred to local physician.
NEUROLOGIC: See neuro flow sheet.
MENTAL STATUS EXAM: Patient is a will nourished, well developed white man in moderate to marked distress. He is tearful during the initial interview. His mood is depressed and his affect is appropriate for the situation. Stream of mental activity is unremarkable, there is no evidence of delusions or ideas of reference. He does have auditory hallucinations. He appears to be of average intellectual functioning. His memory is good for remote and recent events. His general knowledge Is good. Insight and judgment are fair.
INVENTORY OF STRENGTHS AND WEAKNESSES: Patient's primary strength is his recognition of illness and willingness to accept help. Weaknesses include difficulty in dealing with stressful situations and difficulty in controlling impulses at times.
DIAGNOSIS:
AXIS I
1. Major depressive illness, recurrent with suicidal ideation and plan and psychotic features.
2. Panic/Anxiety by history.
AXIS 11
1. No diagnosis.
AXIS III
1. Asthma .
2. Sinus problems.
3. History of chloride gas poisoning.
AXIS IV
1. Psychosocial stressors; primary support.
2. Finances.
3. Wife's illness
AXIS V
1. Current GAP is 28, highest GAF past year 60.
LABORATORY TESTS: Routine laboratory work will be done and any abnormalities will be documented and addressed.
TREATMENT PLAN: Patient will have individual and group therapy. His Wellbutrin will be increased and he will be started on low doses of Seroquei which will be increased if psychotic symptoms are not abated. We will also advise him to get legal help.
PROBLEM SUMMARIES AND RECOMMENDATIONS; This 58-year-old married white male is admitted for treatment of depression with suicidal Ideation and psychotic features secondary to multiple stressors as noted in history and physical.
PROGNOSIS: Fair to good.
ESTIMATED LENGTH OF STAY: 7 to 10 days
DISCHARGE CRITERIA: Resolution of depression, suicidal ideation and auditory hallucinations, follow-up treatment plan in place.
