Prologue

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PARKSIDE 23 HOUR UNIT

HILLCREST PSYCHIATRIC HOSPITAL

DISCHARGE SUMMARY

Patient: Dana Martin

History of Present Illness: This sixteen year-old Caucasian female presented to the Parkside Unit of Hillcrest Psychiatric Hospital for 23 hours observation secondary to extreme emotionalism, explosive behavior, possible drug use, and self-mutilation with threats of suicide.

Admission Diagnostic Impressions:

I Mood Disorder not otherwise specified

    Adjustment Disorder with Disturbance of Emotion and Conduct

    Rule out Substance Use Disorder

II Emerging Personality Disorder not otherwise specified

III No current medical conditions

IV Severe socioeconomic issues

V Global Assessment of Function - 38

Hospital Course: Unremarkable. Patient adjusted well and, other than being overly comfortable around adult men, she displayed no unusual behaviors. By the time of release, she had ceased communicating thoughts of self harm and contracted for safety, stating that if she were to have a recurrence of self injurious behaviors or thoughts, she would immediately inform her parents or other responsible parties in their absence.

Laboratory Studies: A comprehensive metabolic panel, urinalysis and urine drug screen were accomplished during her stay, but a final report was not available at the time of this dictation.

Discharge Diagnostic Impressions:

I Mood Disorder not otherwise specified

    Adjustment Disorder with Disturbance of Emotion and Conduct

    Parent-Child Relational Problem

    Rule out Substance Use Disorder

II Emerging Personality Disorder not otherwise specified.

III No current medical conditions

IV Severe socioeconomic issues

V Global Assessment of Function - 52

Discharge Medications: None

Social Services: Declined by legally authorized representative.

Follow-up: Parents will assume responsibility for continuing safety monitoring and will ensure that Dana presents for psychiatric evaluation at the League City Mental Health Clinic. An appointment has been arranged with Dr. Beverly Anderson, with notice of date and time provided to the family. A report of laboratory investigations should be available by the appointed date. The patient must be returned to the Parkside unit upon recurrence of suicidal ideation, self injurious behaviors, or evidence of danger to others.

Electronically signed

Joseph D. Malone, MD, MPH


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