Patient is a 12 year old male with PPHx of ADHD, DMDD, unspecified intellectual disability and multiple prior hospitalizations, who presents to crisis as transfer from Holtz for SI. Per BA, “patient ran away from home due to his parents finding tobacco products on him […] he was located and refused to go back to his house stating he wanted to go to crisis. He stated he does not feel like he should live anymore”.
Diagnosis *Complaint of Disruptive mood dysregulation disorder (ICD10-CM F34.81, Discharge, Medical) *Complaint of Unspecified mood [affective] disorder (ICD10-CM F39, Discharge, Medical) *Complaint of ADHD (ICD10-CM F90.9, Discharge, Medical)
Discharge plan Condition: Guarded. Admit: To Inpatient Unit. Suicide ideation: No. Homicide ideation: No. Psychiatrically stable: No. I have seen the CSSRS screening performed by the ED nurse and believe the patient has a low risk for suicide. -Admit to Inpatient, Involuntary and Incapacitated -Meds: -Psychotropic: ETOs only -Labs: COVID (pt recently admitted on 10/25) -Safety: No 1:1 sitter acutely indicated at this time. Continue current level of inpatient staff observation.
Discussed with team and will continue to monitor and treat as indicated. Upon interview patient is somnolent, dismissive, antagonistic and unwilling to cooperate with undersigned. He does endorse passive suicidal thoughts with no intent or plan and depressive symptoms including sad mood, anhedonia and poor energy levels. Regarding substance use, he endorses regular cannabis and alcohol use. He is unwilling to disclose reason why he was suspended from school.