[##]-year-old
[male/female] with [depression/suicidal ideations] with history and exam
consistent with likely [presumptive diagnosis].
Initial consideration
in this patient included major depressive disorder, adjustment disorder,
suicide attempt (intentional overdose and self-injury amongst others), alcohol
or other substance related mood disorders, and organic causes of altered mental
status among others.
Patient presented to
the ED [due to concerns over suicidal thoughts/after police were called due to
suicidal comments/after his coworkers/supervisor noted suicidal comments]. On initial exam the patient was noted to be
hemodynamically stable [with/without] evidence of intoxication. Patient noted to have [no] evidence of
[likely] self-injury [specify]. Labs
[were/were not] ordered [and unremarkable as noted above/notable for elevated
ethanol level without other evidence of overdose, illicit drugs or significant
toxins]. The patient expressed [passive
suicidal ideations/no suicidal ideations] in the ED [with/without] plan
[specify].
Patient medically cleared based on history, exam, and workup as noted above with no evidence of significant medical instability or medical condition causing or contributing to psychiatric condition at this time. The patient was
considered to be [moderate/high] risk for suicide based on consideration of
risk factors, including [access to a firearm/suicidal plan involving lethal
means/poor access to outpatient care or social support/unwillingness to safety
contract in the ED/a SAD PERSONS score of ## points consistent with high risk].
http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/
https://edsmartchart.blogspot.com/2020/06/physical-exam-psychiatric-mental-status.html
https://edsmartchart.blogspot.com/2020/06/decision-rule-sad-persons-score.html
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