History and Physical – Rotation 7

Identifying Data:

  • Name: GD
  • Sex: Female
  • Age: 17
  • Date and Time: October 12th, 2022; 2:05 PM
  • Location: NYC H+H/Queens Hospital Center – Emergency Extended Length of Stay (EELOS)
  • Source of Information: Self, Mother, Mother’s boyfriend
  • Source of Referral: Guidance counselor

Chief Complaint: “School sent me here because I said I could kill myself”

History of Present Illness:

GD is a 17-year-old Hispanic female, high school student, domiciled with family, with reported medical history of depressive disorder, OCD, PTSD, who presents to the pediatric ER, brought in by EMS, activated by school guidance counselor, secondary to reported suicidal ideations with plan as well as being found to have a metal fork in her belongings.

Upon psychiatric evaluation in EELOS, patient remains with anxious mood, constricted affect, but is otherwise cooperative with assessment. Patient admits that she told her counselor that she no longer had any reason to live because she has fulfilled all promises and obligations to her friends, family, and therapist, and thusly no longer has any reason to live. Patient reports that every year around her birthday (October 5th) she feels much more depressed than usual because it reminds her of her deceased father. She reports that her father was an NYPD officer who was a first responder on September 11th and passed away when she was 14 due to a 9/11 related illness. Patient admits to suicidal ideations but denies active ideation or intent. Patient endorses long history of non-suicidal self-injurious behavior via forearm cutting throughout her teenage years. Patient also reports approximately 5 times, most recently being September 2021, where she overdosed on medication and did not inform her family or seek medical attention.

Patient is known to follow up without outpatient psychiatrics and is compliant with her medication regimen of Zoloft, Lithium, Topamax, and Prazosin. Collateral information is obtained from the patient’s mother and mother’s boyfriend. As per boyfriend, patient was recently discharged from inpatient psychiatric facility in August 2022 after an 8-week admission.

Past Medical History: Asthma

Past Psychiatric History:

  • Major depressive disorder
  • Obsessive compulsive disorder
  • Post-traumatic stress disorder

Past Surgical History: Patient denies


  • Albuterol pump PRN
  • Sertraline (Zoloft) 100mg PO QD
  • Prazosin HCL 2mg PO HS – for nightmares

Allergies: Patient denies

Family History:

  • Mother: Alive and well
  • Father: Deceased, 9/11/01 related illness
  • Brother: Older, alive, and well

Social History:

  • Employment: Full time high school student.
  • Education: High school senior
  • Travel: Denies recent travel
  • Diet: States that she eats regularly with no dietary restriction.
  • Exercise: Denies regular exercise
  • Sexual Activity: Not sexually active, denies ever having sex.
  • Smoking: Denies current or past use of tobacco products
  • Alcohol: Denies any alcohol use
  • Drugs: Denies use of any illicit drugs.

Vital Signs:

  • BP: 116/72
  • Pulse: 81 beats/minute, regular
  • Respiratory rate: 16 breaths/minute, unlabored
  • Temperature: 98.4F (36.9C), oral
  • SpO2: 100% RA
  • Height: 64 inches
  • Weight: 125 pounds
  • BMI: 24.5

Mental Status Exam:


  • Appearance – GD is a Hispanic female with a narrow frame and long black hair untied. She is dressed in blue hospital-provided pajamas and is well groomed with good hygiene. She appears her stated age. She has multiple superficial abrasions on her right wrist.

  • Behavior – Upon initial evaluation in Emergency Extended Length of Stay unit, the patient is sitting upright in stretcher with good posture, eating a candy bar, thoughts are clear, logical, and easily understood. She does not appear to have any tics, tremors, or psychomotor agitation or retardation.

  • Attitude Towards Examiner – LW is calm and cooperative and responds to all questions appropriately. She appears guarded during the interview yet maintained good eye contact. She does not display any hostility or aggression towards the examiner or other unit staff.

Sensorium and Cognition:

  • Alertness and Consciousness – LW was conscious and alert consistently throughout the interview

  • Orientation – Patient was oriented to person, place, time, and situation

  • Concentration and Attention – LW maintained attention and concentration throughout the interview and did not appear distractible or internally preoccupied. She was able to answer all questions appropriately.

  • Visuospatial Ability – The patient displays normal visual perception as suggested by appropriate balance on her feet, normal gait, and purposeful body movements. She did not maintain consistent eye contact but displayed normal gaze when she did make eye contact.

  • Capacity to Read and Write – LW displayed average reading and writing ability as shown by her reviewing legal holding paperwork provided in unit.

  • Abstract Thinking – The patient displays intact abstract thinking by interpretation of commonly used English metaphors
    • The grass is always greener on the other side – “Things aren’t as good as you hoped when you get them.”
    • What makes apples and oranges similar? – “They are fruits.”

  • Memory – The patient’s remote and recent memory appear normal as suggested by her ability to provide her mother’s phone number from memory and recollection of recent events leading up to her presentation to the facility.

  • Fund of Information and Knowledge – LW’s intellectual performance was average and consistent with her education level.

Mood and Affect:

  • Mood – The patient’s mood appears sad/depressed. She did not smile during the interview. She states that she feels “fine” and wants to go home.

  • Affect – LW appeared guarded and her affect was flat.

  • Appropriateness – LW’s mood and affect were congruent throughout the interview.


  • Speech – LW’s speech rate was slow, rhythm was monotone, and volume was low. Her speech was coherent and organized. The patient’s answer latency was increased. She did not require redirection to answer questions.

  • Eye Contact – LW maintained good eye contact.

  • Body Movements – Patient appeared fidgety during the exam as shown by rubbing her hands together and shifting on the bed. She does not display any tics or unintentional body movements. All movements were fluid.

Reasoning and Control:

  • Impulse Control – LW displays appropriate impulse control. She denies current suicidal or homicidal urges. She is compliant with all requests (urine sample, blood samples, accepting food and drinks etc.)

  • Judgment – LW denies current paranoia, delusions, and auditory/visual hallucinations. Her judgment is appropriate.
    • If you were walking on the street and notices a letter with a stamp and address on the ground next to a mailbox you drop mail in, what would you do? – “I would put the letter in the mailbox.”

  • Insight – LW’s insight is appropriate; she is aware of her current condition and why she was brought to the hospital (“I tried to kill myself earlier.”).

Patient Health Questionnaire – 9:

  • In the past 2 weeks have you felt little interest or pleasure in doing things you used to enjoy?
    • Nearly every day: +3
  • In the past 2 weeks, have you been feeling down, depressed, or hopeless?
    • More than half the days: +2
  • In the past 2 weeks, have you had trouble falling or staying asleep, or sleeping too much?
    • Several days: +1

  • In the past 2 weeks, have you been feeling tired or having little energy?
    • Nearly every day: +3
  • In the past 2 weeks, have you had poor appetite or been overeating?
    • Not at all: 0
  • In the past 2 weeks, have you been feeling bad about yourself or that you are a failure or have let yourself or your family down?
    • More than half the days: +2
  • In the past 2 weeks, have you had trouble concentrating on things, such as reading the newspaper or watching television?
    • Not at all: 0
  • In the past 2 weeks, have you been moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?
    • Not at all: 0
  • In the past 2 weeks, have you thought that you would be better off dead, or thoughts of hurting yourself in some way?
    • Nearly every day: +3

Total Score – 14 – Suggests moderate depression severity; patients should have a treatment plan ranging from counseling, follow-up, and/or pharmacotherapy.

Differential Diagnoses:

MDD: Previously diagnosed. Sadness, anhedonia, decreased energy, decreased concentration, and suicidal ideations are all present. These symptoms cause impairment in social and school settings, are not attributable to effects of a substance or other medical conditions. Patient has never had a manic or hypomanic episode.

PTSD: Previously diagnosed. Experienced the death of her father around the time of her birthday, as he died from a 9/11 related illness. Every year on her birthday she has dissociative reactions of her father in the hospital. Currently has detachment from many of her old friends.


At this time, patient will benefit from overnight behavioral observation in EELOS.

  • Maintain 1:1 behavioral observation at all times
  • Continue patient’s home medication regimen
  • Prior to discharge, create safety plan that includes goals for the future
  • Follow-up with outpatient team
  • Continue efforts for combined schooling and therapeutic program