County General Hospital
546 That Street.
Some Town, YY 12347
111-222-9998
DISCHARGE SUMMARY
PATIENT: Collette Rose
ADMISSION DATE: June 5, 1995
DISCHARGE DATE: June 13, 1995
ATTENDING PHYSICIAN: Jackson, Samantha
UNIT#: 345678
ACCT#: 98734513
DOB: 12/04/78
ROOM/BED: F. 346-B
Issac Johnson, DSA dictating for Dr. Samantha Jackson
DISCHARGE DIAGNOSES:
1. Major Depression
2. Alcohol Abuse
HISTORY OF PRESENT ILLNESS:
This is an 18-year-old Caucasian female with a recent history of major depression and
suicide attempt. She ingested nearly an entire bottle of acetaminophen. Her sister
discovered her passed out in the bathtub and called 911. She was brought to the
emergency department by ambulance. She was admitted for further evaluation,
stabilization and medication management.
ALLERGIES:
No known drug allergies.
HOSPITAL COURSE:
Treatment began in the ambulance on the way to the hospital. Activated charcoal was
administered. Upon admission, gastric lavage was conducted to clean out the contents of
her stomach. Patient’s BAC level was 0.15. She was given fluids to rehydrate her system
after respiratory stabilization.
On the morning of June 13, the patient had calmed down in response to the medication
and care provided the last 7 days. She denied AH/VH. She denied any suicidal or
homicidal ideations. She was prescribed fluoxetine 20mg, once daily.
Dr. Jackson noted that she would need to follow up with social services and XYZ
Community Mental Health Center for ongoing treatment.
CONDITION AT DISCHARGE:
The patient was wanting to be discharged. She was alert and oriented x3. Vital signs
were stable. Her last recorded blood pressure was 107/61, heart rate 75. Lungs were
clear. Abdomen was soft, nontender, nondistended with positive bowel sounds. She was
PT: Rose, Collette
UNIT: 345678
ACCT: 98734513
discharged on June 13, 1995, with discharge instructions given and medications
reconciled.
LABORATORY DATA:
On June 5, sodium 143, potassium 3.8, chloride 109, co2 of 28, anion gap 6.0, glucose
122, BUN 17, creatinine 1.1, total protein 6.5, albumin 3.4, globulin 3.1, calcium 8.8,
phosphorus 3.7, total bilirubin 0.3, AST 14, ALT 15, alkaline phosphatase 88,
magnesium 2.2, triglycerides 50, cholesterol 150, HDL cholesterol 45, and LDL 120.
Hematology values on June 6, white blood count 11.6, hemoglobin and hematocrit 12.3
and 36.5 respectively, with platelet count of 282,000.
DISCHARGE MEDICATIONS:
1. Fluoxetine 20 mg
DISCHARGE INSTRUCTIONS:
Follow up with Social Services as instructed r.e. housing. Follow-up with XYZ
Community Mental Health Center for ongoing treatment.
Dictated by Issac Johnson DSA
DD: 06/14/1995 12:25:34 DT: 06/14/1995 13:15:25 CGHANYHSC; Job#543322
Authenticated by Samantha Jackson MD on 06/15/1995 06:45:21 PM
PT: Rose, Collette
UNIT: 345678
ACCT: 98734513
County General Hospital
546 That Street.
Some Town, YY 12347
111-222-9998
HISTORY AND PHYSICAL REPORT
PATIENT: Collette Rose
ADMISSION DATE: June 5, 1995
ADMITTING PHYSICIAN: Jackson, Samantha
ATTENDING PHYSICIAN: Jackson, Samantha
DICTATING PHYSICIAN: Jackson, Samantha
UNIT#: 345678
ACCT#: 98734513
DOB: 12/04/78
ROOM/BED: F. 346-B
CHIEF COMPLAINT:
The patient came in with major depression following a suicide attempt.
HISTORY OF PRESENT ILLNESS:
This is an 18-year-old Caucasian female with major depression. She complains of
feelings of hopelessness. She has lost interest in every day activities that used to bring
her joy, including caring for her son. She is sleeping 18-20 hours a day and not caring for
her hygiene. She complains of little energy. She reports that she has lost 15 lbs in the
last month. She appears to be underweight for her height.
PAST MEDICAL HISTORY:
The patient has a prior suicide attempt as a juvenile. In 1991, when the patient was 13
years old she took an entire bottle of acetaminophen “to stop the pain.”
SOCIAL HISTORY:
She is single, she recently had a son, is currently unemployed and homeless. She does
not smoke, denies drinking or using drugs but smelled of alcohol at admittance.
FAMILY HISTORY:
None.
MEDICATIONS:
None.
REVIEW OF SYSTEMS:
All other systems are reviewed, otherwise negative.
ALLERGIES:
None.
PHYSICAL EXAMINATION:
GENERAL: The patient is lying in the bed, quietly crying. Occasionally sleeps.
PT: Rose, Collette
UNIT: 345678
ACCT: 98734513
VITAL SIGNS: Significant for patient’s temperature of 99.2, pulse of 88, respiratory rate
of 18, blood pressure of 107/61, and pulse ox of 97%.
HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular muscles
are intact. No icterus, no pallor noted.
NECK: Supple, no jugular venous distention, no thyromegaly.
CARDIOVASCULAR: Regular rate and rhythm, s1, s2 heard. No murmurs, gallops, or
rubs.
CHEST: Clear to auscultation.
Abdomen: Soft, tender to the touch, nondistended.
EXTREMETIES: No edema, No cyanosis.
NUEROLOGIC: Alert and oriented x3 and follows all commands.
LABORATORY DATA:
The patient’s CBC was within normal limits. The patient’s CMP was also within normal
limits.
ASSESSMENT AND PLAN:
Abdominal pain. The patient will be given calcium carbonate and acetaminophen.
Anxiety and agitation. The patient will be given Fluoxetine 20 mg to stabilize. The
patient will get social worker involved for further plan of care. We will start the patient
on antidepressant medications.
If this history and physical was performed prior to admission, but within the last 30 days,
indicate by initialing one of the following:
__I have reassessed the patient and notes that there are no significant changes to the
assessment.
__I have reassessed the patient and note the following significant changes occurred:
DD: 06/05/1995 01:25:30 DT: 06/05/1995 03:14:09 CGHANYHSC; Job#569822
Authenticated by Samantha Jackson MD on 06/07/1995 08:49:45 AM
Samantha Jackson
Report ID: 0998-0098
Electronically Signed by Samantha Jackson on 06/07/1995 at 0932
PT: Rose, Collette
UNIT: 345678
ACCT: 98734513