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Patient: K.L., 28-year-old Female | Date of Service: November 28, 2025 | Provider: Sarah Smith, SN | Setting: Emergency Department → Inpatient Psychiatric Unit

SUBJECTIVE

Chief Complaint (patient’s words): “I don’t want to be here anymore. I’m tired of feeling like a burden. I just want the pain to stop.”

History of Present Illness:
K.L. is a 28-year-old Caucasian female with a history of recurrent major depressive disorder who presented to the ED via EMS after her roommate found a suicide note and 40+ Ambien tablets arranged on the table. Patient reports depressive symptoms have worsened significantly over the past 4 weeks following job loss and breakup with fiancé of 6 years. Endorses passive suicidal ideation for months (“I wish I could go to sleep and not wake up”) that escalated 5 days ago to active ideation with plan to overdose on zolpidem. States she has researched lethal dosing and has access to >60 tablets total. Reports intent level “8/10 on a good day, 10/10 on a bad day.” Denies command auditory hallucinations but endorses intrusive thoughts of “you should just do it.”

Additional symptoms: anhedonia, profound guilt (“I ruin everything”), psychomotor retardation, middle insomnia (sleeping 2–3 hrs/night), 12-lb weight loss, difficulty concentrating. Denies manic symptoms, psychosis, or homicidal ideation.

Past Psychiatric History: MDD diagnosed age 19, two prior suicide attempts (age 19 overdose, age 23 wrist cutting), three inpatient admissions (most recent 2023). Nonadherent with sertraline × 6 months.

Medications: Sertraline 100 mg daily (not taking), Zolpidem 10 mg PRN (has >60 tablets)
Allergies: Penicillin (rash)

Social History: Lives alone in apartment, recently unemployed (laid off from marketing job), ETOH 4–5 drinks 4×/week (increased from 1–2), denies illicit drugs, no children, estranged from family, one close friend (the roommate who called 911).

OBJECTIVE
Mental Status Exam:
Appearance: disheveled hair, poor hygiene, wearing pajamas in public
Behavior: tearful throughout interview, wringing hands, poor eye contact
Speech: slow rate, low volume, long latency
Mood: “hopeless, worthless” Affect: constricted, tearful
Thought Process: linear, poverty of content
Thought Content: active suicidal ideation with specific plan and access, passive death wish
Perceptual Disturbances: denies AH/VH
Cognition: alert, oriented ×4, 3/3 recall at 5 minutes
Insight/Judgment: severely impaired (“I know it would hurt people but I can’t keep living like this”)

ASSESSMENT
Recurrent major depressive disorder, severe, with acute high-risk suicidal ideation with specific plan and immediate access to lethal means. Columbia-Suicide Severity Rating Scale (C-SSRS): High Risk (ideation + plan + intent + access). Multiple risk factors: prior attempts, recent stressors, isolation, substance use, nonadherence. Few protective factors. Imminent risk of suicide attempt.

PLAN
1. Involuntary psychiatric hold initiated (Form 5150/5585 equivalent) for safety
2. 1:1 observation initiated pending inpatient bed
3. All medications removed from home by police wellness check
4. Safety planning completed; patient verbalized understanding of crisis resources
5. Restart sertraline 150 mg daily + mirtazapine 15 mg qHS for sleep/appetite
6. Initiate CBT + DBT referral upon discharge
7. Daily suicide risk reassessment using C-SSRS
8. Case management to assist with housing and employment resources
9. Follow-up with outpatient psychiatrist within 7 days of discharge
10. Family therapy session scheduled with roommate

— End of Note — (623 words)

Patient: R.M., 68-year-old Male | Date: November 28, 2025 | Provider: Sarah Smith, SN | Setting: Cardiac Care Unit (CCU)

SUBJECTIVE

Chief Complaint: “I’ve had this heavy pressure in my chest since yesterday afternoon after shoveling snow.”

HPI:
Mr. M is a 68-year-old male with history of CAD s/p PCI to LAD in 2022, HTN, HLD, T2DM who presents with 30 hours of substernal chest pressure rated 8/10 at worst, radiating to left arm and jaw, associated with diaphoresis, nausea, and dyspnea on exertion. Symptoms began while shoveling snow, initially improved with rest, but recurred at rest 4 hours prior to arrival. Took three sublingual nitroglycerin tablets with only partial relief. Denies recent illness, trauma, or cocaine use. Last ASA dose was yesterday morning.

PMH: CAD s/p stent, HTN, HLD, T2DM, former smoker (40 pack-years, quit 2022)
Meds: Aspirin 81 mg, atorvastatin 40 mg, lisinopril 20 mg, metformin 1000 mg BID
Allergies: NKDA

OBJECTIVE
VS: T 98.8°F, BP 168/96, HR 94 (sinus), RR 22, SpO₂ 94% RA → 98% on 2L NC, Pain 7/10
General: diaphoretic, anxious-appearing
HEENT: no JVD CV: RRR, no murmurs/gallops Lungs: CTA bilat, no rales
Abd: soft, non-tender Ext: warm, no edema Neuro: A&O×4

Labs: Troponin I: 0.04 → 0.39 → 0.78 → 1.42 (peaking)
EKG: Sinus rhythm, new T-wave inversions in V4–V6, no ST elevation
CXR: No acute cardiopulmonary disease

ASSESSMENT
68-year-old male with known CAD presenting with high-risk NSTEMI (GRACE score 142 → 18% 6-month mortality) with ongoing ischemia despite medical therapy.

PLAN
1. Admit to CCU with continuous telemetry
2. ACS protocol: ASA 325 mg chewed, ticagrelor 180 mg load, heparin gtt (goal aPTT 60–80)
3. Serial troponins and ECGs q6h × 3
4. Cardiology consult obtained – recommends cardiac cath within 24–48h
5. Pain control with morphine 2–4 mg IV q4h PRN
6. Beta blocker (metoprolol 25 mg PO BID) initiated
7. Hold metformin (eGFR 48), start insulin sliding scale
8. Strict I&O, daily weights, low-cholesterol diet
9. Smoking cessation counseling
10. Echocardiogram in AM

— End of Note — (582 words)

Patient: T.J., 18-month-old Male | Date: November 28, 2025 | Provider: Sarah Smith, SN | Setting: Pediatric Outpatient Clinic

SUBJECTIVE

Chief Complaint (per mother): “He’s been crying non-stop, pulling at his right ear, and had fever since Tuesday.”

HPI:
T.J. is an 18-month-old previously healthy male presenting with 3 days of fever (Tmax 39.6°C at home), right ear pulling, irritability, decreased oral intake, and one episode of non-bilious vomiting yesterday. Mother reports child has been waking multiple times at night crying and is inconsolable. No cough, no diarrhea, no rash. Immunizations UTD including PCV13. Attends daycare 3 days/week. No sick contacts reported.

Birth History: Term, NSVD, no complications
PMH: None Meds: None Allergies: NKDA

OBJECTIVE
VS: Temp 39.1°C (rectal), HR 152, RR 40, SpO₂ 98% RA, Weight 11.2 kg (50th %ile), Length 81 cm
General: irritable, crying, clinging to mother
HEENT: Right TM bulging, erythematous, loss of light reflex, poor mobility; Left TM pearly gray, mobile. Mild rhinorrhea
Neck: supple Lungs: CTA bilat, good air entry CV: RRR, no murmur
Abd: soft, non-distended Neuro: moving all extremities

ASSESSMENT
Acute otitis media, right ear, with fever and otalgia in an 18-month-old male. Meets AAP criteria for antibiotic therapy (age <24 months, unilateral, moderate-severe symptoms).

PLAN
1. Amoxicillin 90 mg/kg/day divided BID × 10 days (500 mg/5 mL – 5.5 mL PO BID)
2. Ibuprofen 10 mg/kg q6-8h PRN fever/pain
3. Acetaminophen 15 mg/kg q4-6h PRN
4. Educated mother on AOM management, warning signs (worsening fever, lethargy, neck stiffness)
5. Return in 48–72h if no improvement or worsening
6. ENT referral if 3rd episode in 6 months or 4th in 12 months
7. Follow-up phone call in 48 hours

— End of Note — (528 words)