Crisis

Subjective

• Patient (Mr. Marcus Vance, 34 yo M, DOB: 12/08/1990, OHIP: 4928-301-882-AB) brought to ED via EMS at 14:20 on 24/10/2024 on Form 1 for acute suicidal ideation (SI) with plan to overdose on home meds. Reports 3-week hx of worsening depressed mood, anhedonia, terminal insomnia (2–3 hrs/night), and hopelessness following job loss. Endorses active SI; denies homicidal ideation (HI), auditory/visual hallucinations (AVH), or paranoid delusions.

• Reports mild epigastric discomfort and fatigue. Denies intentional ingestion prior to arrival, CP, SOB, or neurological deficits.

• MDD diagnosed 2019. One prior psychiatric admission in 2021 for suicidal crisis. Previously trialled on citalopram; switched to escitalopram 1 yr ago. Non-adherent to meds x 4 weeks. Past CBT x 8 sessions in 2021.

• Hypertension, GERD. Appendectomy (2014).

• Escitalopram (Cipralex®) 20 mg PO daily (non-adherent x 4 wks), amlodipine (Norvasc®) 5 mg PO daily, pantoprazole (Pantoloc®) 40 mg PO daily, melatonin 5 mg PO QHS PRN.

• Lives alone in rented apartment in Toronto. Recently laid off from IT role. Financially stressed. Smokes 0.5 PPD, EtOH 3–4 drinks on weekends (last drink 3 days ago), denies illicit drug use. Sister lives locally and is supportive.

• Penicillin (rash).

Objective

• Alert, oriented x 3. Dishevelled, poor eye contact, psychomotor retardation noted. Speech soft, slow, impoverished. Mood "empty," affect constricted and dysphoric. Thought process linear, goal-directed. Thought content notable for active SI with plan, no intent while in hospital; no delusions or perceptual disturbances. Insight and judgment fair.

• NAD. Cardiovascular: normal S1/S2, no murmurs. Respiratory: clear to auscultation bilaterally. Abdomen: soft, non-tender. Neurological: CN II–XII intact, normal gait, no tremor. Superficial healed linear scars on left volar forearm; no acute self-harm injuries.

• BP 138/86 mmHg, HR 82 bpm, RR 16/min, Temp 36.8 °C, SpO2 99 % on RA.

• CBC, electrolytes, Cr, LFTs, and TSH WNL. Serum EtOH < 2 mmol/L. Acetaminophen and salicylate levels undetectable. Urine tox screen negative. ECG: normal sinus rhythm, QTc 418 ms.

Assessment

• 34 yo M presenting in acute psychiatric crisis secondary to MDD relapse, precipitated by psychosocial stressors (unemployment) and medication non-adherence. High acute suicide risk given active SI with lethal plan, living alone, and history of prior admission, though mitigated currently by hospital containment and willingness to engage in treatment.

• Medically stable. Mild epigastric discomfort likely secondary to GERD and acute stress. No evidence of toxic ingestion.

• Major Depressive Disorder, recurrent, severe without psychotic features; Bipolar II Disorder (rule out, though no hx of hypomania); Adjustment Disorder with depressed mood.

Plan

• Admit to inpatient psychiatry as voluntary patient (Form 1 expired/rescinded as patient agrees to stay). Place on Q15min safety checks. Restart escitalopram (Cipralex®) 10 mg PO daily x 1 week, then increase to 20 mg PO daily. Initiate trazodone (Desyrel®) 50 mg PO QHS PRN for insomnia. Consult inpatient social work for financial/employment resources.

• Continue amlodipine 5 mg PO daily and pantoprazole 40 mg PO daily.

• Daily inpatient psychiatric review. Coordinate discharge planning and outpatient follow-up with community mental health team prior to discharge.

• Discussed diagnosis, rationale for inpatient stabilization, and importance of medication adherence. Reviewed side effects of escitalopram (GI upset, headache, rare activation). Collaborated on preliminary safety planning and obtained consent to contact sister for collateral and support.