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    Abstract

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    Ashley Santelices
    This clinical abstract summarizes a follow-up outpatient visit for a 19-year old female patient with a 3-year history of persistent depressive disorder and prior suicide attempt. She has been stable on her current medication regimen of fluoxetine, olanzapine, and propranolol. On examination, she had depressed mood but no suicidal ideations. Her diagnosis of persistent depressive disorder was continued and her condition on discharge was noted to be stable.

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    Abstract

    Uploaded by

    Ashley Santelices
    190 views2 pages
    This clinical abstract summarizes a follow-up outpatient visit for a 19-year old female patient with a 3-year history of persistent depressive disorder and prior suicide attempt. She has been stable on her current medication regimen of fluoxetine, olanzapine, and propranolol. On examination, she had depressed mood but no suicidal ideations. Her diagnosis of persistent depressive disorder was continued and her condition on discharge was noted to be stable.

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    This clinical abstract summarizes a follow-up outpatient visit for a 19-year old female patient with a 3-year history of persistent depressive disorder and prior suicide attempt. She has been stable on her current medication regimen of fluoxetine, olanzapine, and propranolol. On examination, she had depressed mood but no suicidal ideations. Her diagnosis of persistent depressive disorder was continued and her condition on discharge was noted to be stable.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    190 views2 pages

    Abstract

    Uploaded by

    Ashley Santelices
    This clinical abstract summarizes a follow-up outpatient visit for a 19-year old female patient with a 3-year history of persistent depressive disorder and prior suicide attempt. She has been stable on her current medication regimen of fluoxetine, olanzapine, and propranolol. On examination, she had depressed mood but no suicidal ideations. Her diagnosis of persistent depressive disorder was continued and her condition on discharge was noted to be stable.

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    6/23/2021 OPD Clinical Abstract - RADISH

    PGH Form No. P-310010 (Revised January 2008) [Last updated by: doc_mcaraan@radish.com (06-23-21 09:53 AM)]

    CLINICAL ABSTRACT

    Name of Hospital/Ambulatory Clinic: Case No.: 4565701


    PHILIPPINE GENERAL HOSPITAL Admission: Date: Jun 23, 2021 Time: NA
    Accreditation No.: (PHIC) H91005030
    Address of Hospital/Ambulatory Clinic: Barangay
    TAFT AVENUE, ERMITA 670
    Municipality/City Province Zip Code
    MANILA NCR 1000

    PATIENT'S CLINICAL RECORD


    1. Patient Name 2. Age 19 y 3. Sex F
    Last Name SANTELICES
    First Name JEPT ASHLEY 4. Attending Physician(s) Signature:

    Middle Name DEL ROSARIO


    Caraan, Melissa Nadine [Psych]
    PRC License Number: 135389
    5. Admitting Diagnosis
    Persistent Depressive Disorder, currently in major depressive episode

    6. Chief Complaint
    Follow-up

    7. Reason for Admission


    Not admitted

    8. Brief History of Present Illness/OB History:


    3-year history of consult with Psychiatry following an attempted suicide by drug overdose

    Currently being managed with the following:


    Fluoxetine 20mg 2 capsules
    Olanzapine 5mg 1/2 tablet
    Propranolol 10mg 1 tablet

    9. Physical Examination (Pertinent Findings per System)


    General Survey Awake, alert
    Vital Signs: BP: HR: RR: Temperature:
    HEENT:

    Chest/Lungs:

    CVS:

    Abdomen:

    GU/IE:

    Skin/Extremities:

    Neuro Examination: MSE: Depressed mood, no suicidal ideations

    172.16.187.118/radish/cform/show_opd_abstract/10199 1/2
    6/23/2021 OPD Clinical Abstract - RADISH

    10. Course in the Wards:

    11. Pertinent Laboratory and Pertinent Diagnostic Findings: (CBC, Urinalysis, Fecalysis, Xray, Biopsy, etc)
    None

    12. Surgical Operation/s - Anesthesia (with Date and Time)


    None

    Printed Name and Signature of Surgeon

    Printed Name and Signature of Anesthesiologist

    13. Discharge:
    a. Date: NA b. Time NA
    c. Final Diagnosis:
    Persistent Depressive Disorder, currently in major depressive episode

    d. Condition on Discharge: Stable

    e. Signature of Attending Physician:

    Caraan, Melissa Nadine [Psych]


    PRC License Number: 135389
    (Note: DOCUMENT IS NOT VALID WITHOUT PHYSICIAN'S SIGNATURE)
    14. Signature of Right Thumbmark of Patient or his/her Representative:

    Printed Name & Signature of Patient or his/her Representative:

    Right Thumbmark Printed Name and Signature of Witness to


    (In case patient and representative could not write.) Thumbmark

    172.16.187.118/radish/cform/show_opd_abstract/10199 2/2

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