Psych History and Physicals

PSYCH H&P 1

Amber Shaikh

Psychiatry Rotation

4/13/2021

Queens Hospital Center

Identifying Information:

Name: A.K.
Sex: Female
DOB: 6/28/1997
Date: 4/12/2021 @ 10:30 AM

Location: Queens Hospital Center – CPEP
Source of Information: Self
Source of Referral/Mode of Transport: Brought in by EMS

CC: “I am hearing voices in my head and don’t feel like myself”

Auditory hallucinations and bizarre behavior

History of Present Illness:

AK is a 23 year old Caucasion female patient, unemployed, domicilied with mother (Kathy xxx-xxx-xxxx) father and sister, and with a past and current psychiatric history of Bipolar 1 disorder, anxiety, borderline personality, and polysubstance abuse (cannabis, acid and mushrooms) is brought in my EMS activated by her mother for bizarre behavior and auditory hallucinations.

As per the EMS, the patient was talking to herself loud, and acting very strange. The patient states that she has been talking to her boyfriend in her head for 3 months now, since January. Patient repeatedly states that she “is one with her boyfriend, Harold” and says he talks to her in her head. She says that he is a real person, but has not seen him in a while because he got into trouble with some substance abuse, and is now in rehab. She says this started in January, because she started mediating, and believes that this is what brought it out. Patient states that Harold never tells her to harm self or others, rather says things such as “cover your mouth” and “flush the toilet.” Throughout the interview, the patient would stop and look to the side and have a conversation with Harold, saying things such as “when did we meet again Harold?” and answering them herself. She was also seen pacing the CPEP hallway having a loud and agitated argument with herself/Harold. She also admits to exhibiting manic symptoms such as increased energy, consistent with her bipolar disorder. In CPEP, the patient was seen trying to disrobe herself. She says she often feels like this when shes on a “high.” She has also been having a decreased appetite and need for sleep, with increased energy.

The patient reports to daily cannabis use, because it helps her sleep and calm her anxiety, last use being prior to arrival at the hospital. She also admits to using other substances such as acids and mushrooms in the past. She has been hospitalized in inpatient psych twice in 2018 and 2019 for a month, for exacerbation of her bipolar symptoms. She states that she was following up with an out patient psychiatrist, but stopped 6 months ago. When asked about what medication she has been on, the patient reports that she was prescribed Xanax and Vyvanse, but sold it instead of taking it. Patient was also prescribed Lithium in the past, but stopped taking it due to the side effects. When asked about her bipolar symptoms, patient states that during her highs she often would do drugs, steal things, and prostitute herself. She says she will have increased energy with decreased need for sleep, and a decreased appetite, all things that she is currently experiencing. During her lows, she would feel more depressed and sad. Currently, the patient denies any suicidal ideation, homicidal ideation or visual hallucinations. She is cooperative on evaluation and is answering all questions well, but is easily agitated at times. She is trying to disrobe herself at times, and has occasional loud conversations with herself. Patient displays poor insight, judgment and impulse.

Collateral information:

Point of contact: mother- Kathy

Number: xxx-xxx-xxxx

The mother states that her daughter has seemed “off” for a month, and has not been sleeping for the past 6 days. She says that she has been having bizarre conversations in her head and says that her boyfriend is inside her. Mother states that since last week, the patient has been walking around the neighborhood in her underwear, and has been talking to “Harold” the whole time. The mother states that the boyfriend, Harold, is actually in a coma, and has not actually seen him in several months. She states that the patient met Harold last year, and that he is homeless. Mother states that the patient was physically abusive towards her 4 days ago, but did not report her. She says that the daughter was not always like this, and the hallucinations began earlier this year. She reports the daughter is always laughing and arguing with herself, and is out of touch with reality. Mother says that when she was 16 she was followed by a psychiatrist, but never took any of the medications she was prescribed. Mother states that she uses Marijuana daily and always acts a little paranoid and anxious, but not this severe.

Past Psychiatric History:

Bipolar 1 disorder (HCC) F31.0
Diagnosed in 2015

Schizoaffective disorder (HCC) F25.9
Diagnosed in 2015
Borderline personality disorder
Diagnosed in 2017
Substance abuse induced mood disorder

Diagnosed in 2015

Past Surgical History:

No notable surgical history.

Past Medical History:

Bipolar type 1
Schizoaffective
Denies any other medical history

Allergies:

No known drug, environmental, or food allergies.

Medications:

Vyvanse (Lisdexamfetamine dimesylate) 30mg tablet-once a day
Patient was prescribed this in 2015, but stopped taking it 2 years ago
Xanax (Alpazolam) PO 0.5mg 3 times a day
Patient was prescribed this in 2015, but stopped take it 2 years ago
Lithium (Lithobid) PO 900mg tablet: q12hr

Patient was prescribed this in 2015, but stopped taking it last year because of side effects.

Family History:

Father also suffered from auditory hallucinations when he lost his father, but resolved in a short amount of time. Mother is diagnosed with Major Depression disorder

Family med history:

Mother: DM, alive and well

Father: HTN, alive and well

Social and Occupational History:

A.K is a 23 year old single, Caucasian female, unemployed, who has her GED and never went to college, domiciled with mother, father and sister. Patient has lived in Queens NY her whole life. The patient is unemployed and is financially supported by her parents. She states that her parents don’t believe her and becomes agitated when asked about them. The patient has gotten into a physical altercation with her mother in the past, where she ended up hitting her, but has never been arrested or gone to jail. The patient denies every being sexually or physically assaulted in the past. She has a strong history of poly substance abuse (cannabis, LSD, acid, and mushrooms), last use of cannabis was prior to arrival to the hospital. She denies any recent use of alcohol or tobacco. Patent has a history of being hospitalized in the psych unit in 2018 and 2019.

Review of Systems:

General – Patient admits to feeling fatigued but denies other constitutional symptoms such as fever and unintentional weight loss or gain, chills, or night sweats
Skin – Patient denies any scars, lesions, discolorations, masses or pruritis. Skin has no signs of track marks or IV drug use. Skin is well hydrated with good turgor and moisture.

Neurology – Patient denies headaches, changes in vision, problems with balance, loss of consciousness, unsteady gait, confusion, or any unintentional body movements.
Psychiatric – Patient admits to auditory hallucinations but denies depression, anxiety, memory deficits, and current mood changes.

Vital Signs:

BP: 126/86 right arm, sitting

Pulse: 117 beats per minute
Respiratory rate: 17 breaths/minute unlabored
Temperature: 98.1 F (oral)
SpO2: 98% (room air)
Height: 5’2”

Weight: 128 pounds
BMI: 23.4

Physical Exam:

General survey: 23 year old female Caucasian female, alert and oriented to person, place and time. Dressed in a hospital robe, occasionally trying to expose herself

Skin: There are no masses or lesions. No evidence of any self-inflicted wounds or any signs of IV drug use, or skin picking

Head/neck: Pupils are equal, round and reactive to light. There are no neck masses or signs of trauma or scratch marks

Psych: patient is very fatigued and tired. She is actively having auditory hallucinations with her boyfriend Harold. She denies any suicidal or homicidal ideations at this time.

Mental Status Exam:

General

Appearance: AK is an average build and height Caucasian female with blonde hair. She is dressed in the hospital gown, but at times is trying to open her gown and expose her breast. She has good hygiene. She looks her stated age. Patient does not appear to have any wounds or injuries.
Behavior and Psychomotor Activity – Throughout the interview, the patient kept breaking the conversation to talk to and answer her boyfriend that was talk to her in her head. She occasionally wound look to the side and say things like “not now Harold, im talking to the doctor.” She had good eye contact and appropriate gesture. Patient had no tics or tremors.
Attitude Towards Examiner – The patient was cooperative with the examiner, but had moments of agitation. She answered all questions well, and was very kind to the doctor and students.

Sensorium and Cognition

Alertness and Consciousness – The patient was conscious and alert throughout the interview, and did not fluctuate throughout.

Orientation – The patient was oriented to person, time and place. And knew why she was in the CPEP.
Concentration and Attention – AK was at times internally preoccupied and was responding to internal stimuli. She would break the conversation to talk to the voice in her head. She is able to answer all questions in an appropriate manner.
Visuospatial Ability – the patient displayed good visuospatial ability and normal perception. She knows were her room is, and can easily guide herself through the CPEP floor. She has appropriate balance and normal gait. She has no tics or tremors, or other unintentional movements.
Capacity to Read and Write – AK presented with average reading and writing abilities, consistent with her level of education.
Abstract Thinking – The patient demonstrates proper capacity for abstract thinking by interpreting common metaphors. An example was “dont cry over spilled milk” she interpreted as “dont worry about the small things”

Memory – The patient displays no impairment of recent and remote memory, as she is able to recall the events prior to her getting to CPEP, and what was happening to her last year.
Fund of Information and Knowledge –AK has good amount of knowledge for her education level, as witnessed by the vocabulary she used during the interview
Thought pattern/process: illogical at times, with fight of ideas. Patient is saying one thing, then gets preoccupied with the hallucination.
Thought content: patient had some odd beliefs, with paranoid thought content. She was very heavily convinced that Harold was inside her.

Mood and Affect

Mood – The patient’s mood was anxious. She would get calm at times throughout the interview, but then would get anxious again.
Affect – Her affect at times was guarded, but when given the space and time to answer the questions, her affect became normal.
Appropriateness – The patient’s mood and emotions were congruent with eacbother, and she went from moments of calm to moments of anxious, along with having her hallucinations. She is however acting inappropriately at times while trying to expose her breast.

Motor

Speech – AK spoke with pressured speech with some increased rate. She was disorganized and illogical in her word content. Her volume was low, but became loud when she was responding to the voice in her head.
Eye Contact – Patient maintained appropriate eye contact throughout the interview.
Body Movements – The patient sat on her bed the whole time while having the interview, and had no abnormal or unintentional movements. She would just look to the side when she was responding the internal stimuli.

Reasoning and Control

Impulse Control – The patient displayed impaired impulse control, as she would randomly get distracted by the auditory hallucinations. She is also trying to expose her breasts, and has to be to button her shirt.

Judgment – Patient displays an impairment in judgement as seen by her responses to the internal stimuli. She believes that her boyfriend is inside her and talks to her, while he in fact is in a coma and has not seen her in many months.
Insight – Patient displayed poor insight as she is convinced that the voice in her head is real. She understands she has bipolar disorder, but thinks that these hallucinations are due to her meditation and believes she had a break through, rather then due to a psych issue.

Differential Diagnosis

Substance Use psychosis Disorder (F19.959) – Patient admits to a history of polysubstance abuse (cannabis, LSD, mushrooms). She also states that she uses Cannabis daily, including the day of admission to the hospital. Long term use of cannibis is shown to cause long term psychosis for several months. Cannabis misuse is also linked to having symptoms such as auditory hallucinations, which the patient is exhibiting. Since he also has a previous psychiatric history of bipolar and substance induced mood disorder, this can all be exacerbated with continuous cannabis use and misuse of other substances.
Schizoaffective Disorder, Bipolar type – The patient displays both features of schizophrenia symptoms, such as hallucinations, along with mood disorder symptoms of bipolar type 1. I believe it would be the bipolar subtype, due to her manic episodes. She has a history of diagnosed bipolar type 1, and is currently showing some signs of mania by using cannabis, having moments of agitation and trying to expose herself. On top of this she is also showing signs of psychosis, by having auditory hallucinations of her boyfriend for over 3 months now. Her hallucinations were going on for longer then her breif episodes of mania and depression.
Bipolar Disorder Type 1 (F31.9)– Patient has a past medical history of Bipolar 1 disorder, that is currently not treated. She describes going through phases of highs and lows. During her highs she has a lot of energy, starts to hear voices, and acts impulsively. During manic episodes she has sex, prostitutes herself, abuses substances, and eats less. During her low episodes she feels depressed, sad, and sleeps excessively. Currently she is having signs of mania due to cannabis use, hallucinations, and attempting to expose herself. I feel that this is less likely considering that her main symptom hallucinations is not a direct example of a manic behavior, as it is more psychosis.
Schizophreniform disorder: The patient has been exhibiting her unusual behvaior and has been having these hallucinations for 3 months. Schizophreniform is having symptoms of two of the following, delusions, hallucinations, and disorganized speech, for between 1 – 6 months. Based on this, our patient fits this timeline. However, I feel like this is less likely, because she is also exhibiting symptoms of bipolar mania and her symptoms are significantly impacted by her chronic daily use of cannabis, which is not under the umbrella of schizophreniform criteria

Diagnosis

Substance induced psychotic disorder

Assessment:

23 year old Caucasian female with a past psych history of Bipolar disorder, schizoaffective disorder, polysubstance abuse, and borderline personality who is domiciled with mother and father and unemployed is brought in by EMS secondary to bizarre behavior and auditory hallucinations. Upon evaluation the patient, she is very disorganized and is having illogical thinking. She continuously keeps responding to an internal stimuli, and says that “Harold (boyfriend) is within me.” Patient admits to daily cannabis use, last use was the day of arrival to the hospital The patient has poor insight, impulse and judgement. As per her past psych history, current presentation, and mental status exam, patient’s diagnosis is most consistent with Substance induced psychosis disorder. Patient will be admitted to CPEP for further observation and evaluation.

Treatment Plan:

First admit patient to CPEP for observation and stabilization
Upon initial evaluation, the patient was showing obvious signs of psychosis that need to be monitored and followed by the psychiatric team. Also considering that the patient has a strong past psych history, she should be observed in a safe environment, rather then being discharged.
Administer Ativan 2mg and Haldol 5mg PO
Upon arrival to CPEP, the patient was very irratable and was having a heated loud conversation with herself. Patient was acting agitated towards the nurses and staff and had to be stabilized.

The following labs will be ordered:
THC: this tests the level of marijuana in the blood. This test is needed since the patient admits to daily use, and use the day of arrival.
CBC and BMP: to assess for any signs of anemia or infection. And to check her electrolytes and glucose as she has had decreased appetite.
Urine toxicology: to test for evidence of substance abuse in the urine, such as marijuana, cocaine, amphetamines, PCP and opiates. Since our patient is a polysubstance abuser, this is important to check.
Beta hCG: Since the patient is 23, and has a history of prostituting her self and having increased sexual activity, it is important to check for pregnancy. Also since she is a substance abuser, knowing if she is pregnant or not is also very important.

Amphetamine: to asses the level of the substance in the body
Blood alcohol level: Even though the patient states that she does not drink alcohol, it is important to check considering she has a history of using other substances.
Zyprexa 10mg once a day prescribed: in order to control patients mood and manic symptoms.
Maintain regular diet
Keep patient on observation every 15 minutes in order to assess for fluctuations in mood

Continue communication with Collateral (mother) to keep her informed and obtain any new information.
Revaluate in the morning for possible inpatient admission

Morning Assessment:

Upon evaluation the next morning, the patient was more calm and alert and responsive to verbal stimuli. She is talking to her self in a calm manner and says that “Harold is talking to me well” she said “he was mad at me the past few days, but is better now.” She reports not getting enough sleep, but is having a good appetite. She says she still feels anxious and is asking for marijuana as it helps her relax and sleep. Patient is still internally preoccupied but is less agitated. Upon re-evaluation, the patient will be admitted to inpatient psych at N3, and will be followed by a psychiatrist. She will then have a reevaluation of her medications, and will be told the importance of compliance.

PSYCH H&P 2

Amber Shaikh

Psychiatry Rotation

4/18/2021

Queens Hospital Center

Identifying Information:

Name: DW
Sex: Female
DOB: 4/28/1985
Date: 4/14/2021 @ 11:30 AM

Location: Queens Hospital Center – CPEP
Source of Information: Self
Source of Referral/Mode of Transport: Brought in by EMS

CC: “depressed mood and suicidal thoughts”

History of Present Illness:

DW is a 36 year old African American female, married, domiciled with husband and 3 children, Employed as a Quality Assurance Test lead, with a past psych history of post-partum depression and previous suicide attempts, brought in by EMS activated by self complaining of depression and suicidal ideation.

She states that for the past few weeks she has been feeling very overwhelmed and anxious and had a verbal argument with her husband last night regarding him minimizing her depressive symptoms and emotions that triggered her suicidal thoughts. She says since the pandemic her children have been at school at home, and her husband is also laid off on and off so has been very overwhelmed with everyone at home, and having to take care of everything while working from home. She says she had post-partum depression in 2014 after having her twins, and sought help from a therapist. She used to be on Paxil when she was younger, but stopped at 18 y/o due to side effects. She also has a history of previous suicide attempt when she was 15, as she tried to cut herself and overdose on medication, for which the patient was hospitalized for 1 month. Patient also reports that April 11^th is the anniversary of her mothers death, so she often feels like this this time of the year. Patient reports a persistent depressed mood, rating it a 9/10, with symptoms of anhedonia, hopelessness, lack of energy, and decreased sleep, with recurrent sad thoughts in the night. She uses marijuana to help her sleep. During the interview, she states “I feel that everyone will be better off without me.” Patient states that her husband does not listen to her when she talks about her emotional thoughts, and often gets into arguments with her about how to raise and discipline the kids. She says he states things like “did you hug the kids tonight” that triggers her and makes her feel like she is not doing her job. She has a great relationship with the kids, but has been very overwhelmed since they have been at home due to the pandemic. Over all, she states that she has done “talk therapies” in the past, with some relief of symptoms and is open to finding a psychiatrist again. She denies any current suicidal thoughts, homicidal ideations, or any auditory or visual hallucinations. On evaluation, that patient was very calm and cooperative, alert and oriented, and is answering all questions appropriately.

Collateral:

Point of contact: Husband

Number: xxx-xxx-xxxx

The patients husband expresses a lot of concern for her anxiety and mental health. He states she is very overwhelmed, but does not share anything with him. He says she has very closed off towards him, and wants to do everything herself, and doesn’t except his help or suggestions. He states that every year in April she goes through the same emotions and feelings, since it is the anniversary of her mother’s death. He says she is a tough person to talk to, as she never reaches out for help. He says that last night she stated that “she does not want to be a wife or mother any more” and that “there’s 3 places in the house that she can kill herself in, where no one can find her.” He expresses concern for her to come home, as it will be a stressful environment for her. He says she may be better off going to her cousin’s house in Brooklyn.

Point of contact: cousin

Number: xxx-xxx-xxxx

Spoke to patients cousin who states that she is concerned for the patients health, as she is always anxious and overwhelmed. She believes that the husband has been a trigger for her in the past few weeks as he does not give her the space she needs. She states how she has always had to take care of herself after her mother passing away. She says she hasn’t seen her in person for a while, but speaks on the phone with her regularly, and is there for her as a support system.

Past Psychiatric History:

Major depressive disorder

Diagnosed 2004

Post-partum depression

Diagnosed 2014

Prior suicide attempt

2000

Past Surgical History:

No notable surgical history.

Past Medical History:

Denies any medical history aside from the past psych history mentioned above

Allergies:

No known drug, environmental, or food allergies.

Medications:

Paxil (Paroxetine) 20mg PO daily QD

Prescribed in 2004-but patient stopped taking it 2 years after due to side effects

Family History:

Emotionally abusive father. Mother deceased when the patient was 8 years old due to cirrhosis caused by alcohol abuse. Patient also mentions her Aunt Diana, who she was very close to, committed suicide in 2008 by jumping out of a window.

Social and Occupational History:

DW is a 36 year old married African American female, employed as a Quality Assurance Test lead, who has her college degree, domiciled with husband and 3 kids. Patient lives in Queens NY, and has family in Brooklyn. The patient says her husband is on and off unemployed, and is the main financial support of the family. The patient has a history of depressive symptoms, with a suicide attempt at the age of 15, for which she was hospitalized in a inpatient psych center, She says her mother passed when she was 8, and that her father has been very emotionally abusive. The only substance she admits to using is marijuana for anxiety and to help her sleep, she denies drinking alcohol or smoking cigarettes or using any other illicit drugs. She denies ever going to jail or every being psychically or sexually assaulted in the past.

Review of Systems:

General – Patient admits to feeling fatigued and sad but denies other constitutional symptoms such as fever and unintentional weight loss or gain, chills, or night sweats
Skin – Patient has a healing scar on her right wrist from prior suicide attempt when she was 15, but denies any other lesions, discolorations, masses or pruritis. Skin has no signs of track marks or IV drug use. Skin is well hydrated with good turgor and moisture.

Neurology – Patient denies headaches, changes in vision, problems with balance, loss of consciousness, unsteady gait, confusion, or any unintentional body movements.
Psychiatric – Patient admits to depressed mood, anxiety and suicidal thoughts but denies any auditory/visual hallucinations, homicidal ideations, memory deficits, and current mood changes.

Vital Signs:

BP: 130/71 right arm, sitting

Pulse: 78 beats per minute
Respiratory rate: 18 breaths/minute unlabored
Temperature: 98.7 F (oral)
SpO2: 100% (room air)
Height: 5’5”

Weight: 165 pounds
BMI: 27.5

Physical Exam:

General survey: 23 year old female Caucasian female, alert and oriented to person, place and time. Dressed in a hospital robe, occasionally trying to expose herself

Skin: There are no masses or lesions. No evidence of any self-inflicted wounds or any signs of IV drug use, or skin picking

Head/neck: Pupils are equal, round and reactive to light. There are no neck masses or signs of trauma or scratch marks

Psych: patient is very fatigued and tired. She is actively having auditory hallucinations with her boyfriend Harold. She denies any suicidal or homicidal ideations at this time.

Mental Status Exam:

General

Appearance: DW is an average build and height African American female, who is causally groomed and well-nourished. She is dressed in a hospital gown, and is wearing a baseball cap. She ahs good hygiene and looks her stated age. Patient does not appear to have any wounds or injuries.
Behavior and Psychomotor Activity –Throughout the interview, the patients behavior is within normal limits.
Attitude Towards Examiner – Patient is alert and cooperative with the examiner and with the students. She is answering all questions well and is supplying the information that is being asked.

Sensorium and Cognition

Alertness and Consciousness – The patient was conscious and alert throughout the interview, and did not fluctuate throughout.
Orientation – The patient was oriented to person, time and place. And knew why she was in the CPEP.
Concentration and Attention – DW has good concentration throughout the interview, and did not fluctuate. She payed proper attention to the questions being asked, and answered them all appropriately.
Visuospatial Ability – the patient displayed good visuospatial ability and normal perception. She knows were her room is, and can easily guide herself through the CPEP floor. She has appropriate balance and normal gait. She has no tics or tremors, or other unintentional movements.
Capacity to Read and Write – AK presented with average reading and writing abilities, consistent with her level of education.

Abstract Thinking – The patient demonstrates proper capacity for abstract thinking by interpreting common metaphors. An example was “dont cry over spilled milk” she interpreted as “dont worry about the small things”
Memory – The patient displays no impairment of recent and remote memory, as she is able to recall the events prior to her getting to CPEP, and what was happening to her last year.
Fund of Information and Knowledge –AK has good amount of knowledge for her education level, as witnessed by the vocabulary she used during the interview
Thought pattern/process: No thought disorder present. Patient has a good flow of ideas, flowing from one question to the next in an appropriate manner.
Thought content: Patient’s thought content was unimpaired

Mood and Affect

Mood – The patient’s mood was sad, depressed and anxious throughout. She would at times get tearful throughout the interview.
Affect – Her affect at times was constricted
Appropriateness – The patient’s mood and emotions were congruent with each other, as she was sad and tearful throughout the interview. Patient appeared appropriate with the staff and other patients throughout her stay.

Motor

Speech – AK spoke with normal speech and at a good rate. At times she would take a little longer answering questions, because of her getting emotional and tearful.
Eye Contact – Patient maintained appropriate eye contact throughout the interview.
Body Movements – The patient sat on her bed the whole time while having the interview, and had no abnormal or unintentional movements. She would at times cross her arms over each other

Reasoning and Control

Impulse Control – The patient displayed good impulse control throughout her stay.
Judgment – Patient displays fair judgment, as she understood why we were keeping her there. Patient understood the importance of her health.
Insight – Patient displayed poor insight as she is convinced that people would be better of without her. She is very overwhelmed, and understands she needs help, but does not believe that her husband is trying to care for her. She feels like she is all alone in this situation.

Differential Diagnosis

Major depressive disorder, without psychosis – Patient admits to a past psych history of MDD, for which she was on Paxil for but stopped taking at 18. She is exhibiting symptoms of anhedonia, depressed and sad mood, low energy, decreased sleep, lack of interest in doing any activities, as well as suicidal thoughts. These symptoms have been ongoing for a long time on and off, but have been consistent since last march when the pandemic started. She also has a prior history of suicide attempt. She is not exhibiting any signs of psychosis at this time, even though she is a daily cannabis user.
Adjustment Disorder, with mixed anxiety and depressed mood– This occurs when one goes through a major life stressor or life changing moment. The time line of this is within 3 months of going through a life changing moment, one starts to exhibit depressed and anxious symptoms. Our patient states multiple times that the pandemic is caused an increased amount of stress in her life, as her kids are home schooled, and her husband wa slaid off. Having everyone at home due to the COVID 1 infection, could be the life changing stressor that has lead to the depressed mood and suicidal thoughts in out patient. There are multiple types, our patient displays aspects of anxiety and depressed, because she is sad and tearful with feelings of hopelessness, along with feeling constantly overwhelmed and worried.
Generalized Anxiety Disorder– This is when the patient constantly worries and stresses about things that are not in their control. The time line of this is when one worries for at least 6 months, about things that can pertain to money, family, work, etc. Our patient can display this because she is constantly worried about her family, her job, and the pandemic. This is however lower on my differentials because it is not necessary for one who suffers from GAD to have feelings od depression, which is our patients main concern.

Bipolar type 2 disorder: Bipolar type 2 is when one has fluctuating symptoms of hypomania and depression. Hypomania is described as when someone has moments of highs that are not to the extent of mania, this can include elated or irritable mood and increased energy. Our patient has definitely shown to exhibit the depressive and low aspects of bipolar type 2, but has not expressed moments when she is hypomanic. This is less likely, since our patient states that she is constantly in a low mood for several months at a times, and does not express moments that can be considered hypomanic.

Diagnosis

Major Depressive Disorder, without psychosis

Assessment:

36 year old African American female with a past psychiatric history of major depressive disorder and a prior suicide attempt, who is domiciled with husband and 3 children is brought in by EMS activated by self secondary to depressed mood and suicidal thoughts. Upon evaluation of the patient, she is very sad and depressed and is tearful throughout the interview. However, she is organized in her speech pattern an dis having logical thinking. She mentions how overwhelmed she is with everyone being home due to the pandemic, and how she has to take care of everyone. She also states that her husabnd has become a trigger for her as he minimizes her depressive symptoms, and does not actively listen. She also states that this month is the anniversary of her mother’s passing, and often feels like this during this time of year. She admits to daily cannabis use to help her with her anxiety and sleep, but denies using any other substances. The patient has poor insight, but fair impulse and judgement. As per her past psych history, current presentation, and mental status exam, patient’s diagnosis is most consistent with Major Depressive disorder, without psychosis. Patient will be admitted to CPEP for further evaluation and observation.

Treatment Plan:

First admit patient to CPEP for observation and stabilization

Since she has had suicidal thoughts, and has a history of a past suicide attempt, it is important to monitor the patient in a safe environment.

The following labs will be ordered:

CBC with differential, CMP: to monitor blood levels for any signs of infection, and to monitor electrolyte and glucose levels

THC: to test the level of marijuana in the blood. Since patient states she is a daily user, it is important to know if she has signs of it in her blood
BetaHCG: as patient is a women of child bearing age, this is vital to obtain
Drug panel: since the patient admits to using marijuana, this allows us to check if she uses any other substances.
Amphetamine use: check the level in the blood
COVID: in case patient was exposed or is positive herself.

Medication reconciliation: Will start the patient on Lexapro 10mg PO Daily QD

In order to control ones depressive mood and symptoms.

Maintain regular diet
Keep patient on observation every 15 minutes in order to assess for fluctuations in mood
Continue communication with Collateral (husband and cousin to keep her informed and obtain any new information.

Revaluate in the morning for possible inpatient admission
Refer the patient to an outpatient psychiatrist

PSYCH H&P 3

Amber Shaikh

Psychiatry Rotation

4/13/2021

Queens Hospital Center CPEP

Identifying Information:

Name: C.O
Sex: Female
DOB: x/xx/xxxx
Date: 4/20/2021 @ 9:30 AM

Location: Queens Hospital Center – CPEP
Source of Information: Self
Source of Referral/Mode of Transport: Brought in by EMS

CC: paranoid behavior, here for a psych eval

History of Present Illness:

CO is a 45 year old Nigerian female, domiciled with husband and 3 children, unemployed, with a past psychiatric history of bipolar disorder and a past medical history of hypertension who was brought in by EMS and NYPD activated by husband for paranoid and aggressive behavior.

The patient continuously states that she is convinced her husband is cheating on her. She says her husband has been sleeping with several women in their church. She was seen in the psych facility on 4/12 with similar beliefs. At that time the patient was convinced that someone was trying to steal from her and take her husband. Her husband stated that she had not slept for 3 days. Patient was kept in CPEP for 3 days and was discharged on 4/15. Today she presents with similar complaints. Patient says she has not slept in 3 days, and is distrusting of her husband saying that he has been having an affair with several women. She also says that “someone has stolen millions of dollars” from her bank account. Patient states that while watching TV the night prior she heard people on the Steve Harvey show talk to her, and believes that they were talking about her husband’s infidelity. Patient is also expressing grandiose thoughts, as she thinks she is a famous celebrity. Patient denies ever using any illicit substances or drinking alcohol. She states she is currently not on any psychiatric medications and is not followed by a psychiatrist. The Patient’s mother and husband state that she has had these episodes in the past but refused to receive any treatment by a psychiatrist. She denies any suicidal ideations. Homicidal ideations or any auditory/visual hallucinations.

Upon eval, the patient is loud, aggressive, and uncooperative. Patient is speaking in loud and pressured speech. She is minimizing her symptoms and is demanding discharge. She is alert and oriented to person, place and time but is irrational at times and is talking to self with flight of ideas. She has poor impulse and insight, and is very agitated and aggressive to staff. Patient had to be medicated with Haldol 5mg and Ativan 2mg.

Collateral information:

Point of contact: Husband

Phone number: xxx-xxx-xxxx

Spoke to the patient’s husband who states that for the past several days the patient has been loud and exhibiting bizarre behavior. He says she has not slept in the past 3 days, and was just seen in the psych ED 1 week ago for the same complaint. He says the patient is constantly accusing him of infidelity. He states that she is exhibiting strange jealousy behavior, and is convinced that he is having an affair with multiple women in the church. He states that she became very aggressive with him when he was having a conversation with her and slapped him on both cheeks, and said “do you know who I am? I am a star.” She then proceeded to drive away in a car with the door open, and forgot that her daughter was inside the car. She has been very erratic all week and has barely slept, but has maintained an healthy appetite. He denies ever witnessing her using an substances or alcohol. He states that the patient has never seen a psychiatrist, but thinks that she should. He mentioned that he does not feel safe at home if the patient were to be discharged, and says that she should be given a prescription medication to prevent these symptoms from reoccurring.

Past Psychiatric History:

Bipolar 1 disorder (HCC) F31.0
Diagnosed in 2010

Past Surgical History:

No notable surgical history.

Past Medical History:

Hypertension

Diagnosed in 2015
Controlled with diet and exercise

Allergies:

No known drug, environmental, or food allergies.

Medications:

Paragard IUD in place in 8/28/19

Family History:

No family psych history

Family med history:

Mother: DM, alive and well

Father: HTN, alive and well

Social and Occupational History:

CO is a 45 year old married, Nigerian female, unemployed, who has her Associates degree, and is domiciled with husband and 3 kids. She says she was previously employed as a home health aide, but was let go due to the pandemic, and is now financially supported by her husband. Patient has lived in Queens, NY her whole life. She states her children are 17, 15 and 9 years old, and that she takes care of them well. The patient has gotten into a physical altercation with her husband, but has never been arrested or gone to jail. She denies ever being sexually or physically assaulted in the past. She denies using any substances such as cannabis, or drinking alcohol. Patient was recently seen for the same complaint in the psych ED less then 1 week ago.

Review of Systems:

General – Patient admits to feeling anxious at times but denies other constitutional symptoms such as fever and unintentional weight loss or gain, chills, or night sweats
Skin – Patient denies any scars, lesions, discolorations, masses or pruritis. Skin has no signs of track marks or IV drug use. Skin is well hydrated with good turgor and moisture.

Neurology – Patient denies headaches, changes in vision, problems with balance, loss of consciousness, unsteady gait, confusion, or any unintentional body movements.
Psychiatric – Patient admits to thinking her husband is cheating on her but denies any auditory hallucinations, increased energy, depression, and memory deficits

Vital Signs:

BP: 130/92 right arm, sitting

Pulse: 75 beats per minute
Respiratory rate: 18 breaths/minute unlabored
Temperature: 98 F (oral)
SpO2: 99% (room air)
Height: 5’4”

Weight: 155 pounds
BMI: 26.6

Physical Exam:

General survey: 45 year old Nigerian female, alert and oriented to person, place and time. Dressed in a hospital robe.

Skin: There are no masses or lesions. No evidence of any self-inflicted wounds or any signs of IV drug use, or skin picking

Head/neck: Pupils are equal, round and reactive to light. There are no neck masses or signs of trauma or scratch marks

Psych: patient is anxious to leave and has bouts of increased energy. Denies any auditory or visual hallucinations, or any suicidal/homicidal ideations.

Mental Status Exam:

General

Appearance: CO is of average build and height. She is a Nigerian woman with dark hair. She is casually groomed and dressed in a hospital gown. She has good hygiene and looks her stated age. Patient does not appear to have any wounds or injuries.
Behavior and Psychomotor Activity – Patient is restless and agitated. She appears to be responding to internal stimuli, and keeps insisting on being discharged. She keeps pacing the CPEP floor and coming up to the window looking to ask the doctor when she can leave. She had good eye contact and appropriate gesture. Patient had no tics or tremors.
Attitude Towards Examiner – The patient was cooperative with the examiner, but had moments of agitation. She answered all questions well, and was kind to the doctor and students.

Sensorium and Cognition

Alertness and Consciousness – The patient was conscious and alert throughout the interview, and did not fluctuate throughout.
Orientation – The patient was oriented to person, time and place. And knew why she was in the CPEP.
Concentration and Attention – patient was at times internally preoccupied and was responding to internal stimuli. Her concentration was impaired at times as she would forget the question being asked and insist on leaving.
Visuospatial Ability – the patient displayed good visuospatial ability and normal perception. She knows were her room is, and can easily guide herself through the CPEP floor. She has appropriate balance and normal gait. She has no tics or tremors, or other unintentional movements.
Capacity to Read and Write – AK presented with average reading and writing abilities, consistent with her level of education.

Abstract Thinking – The patient demonstrates proper capacity for abstract thinking by interpreting common metaphors. An example was “dont cry over spilled milk” she interpreted as “dont worry about the small things”
Memory – The patient displays no impairment of recent and remote memory, as she is able to recall the events prior to her getting to CPEP, and what was happening to her last year.
Fund of Information and Knowledge – the patient has good amount of knowledge for her education level, as witnessed by the vocabulary she used during the interview
Thought pattern/process: illogical at times, with fight of ideas. Patient is saying one thing, then gets preoccupied with another thought.
Thought content: Patient is displaying grandiose thoughts, with paranoid ideas about her husband.

Mood and Affect

Mood – The patient is irritable, angry and anxious. She is easily triggered and agitated at the nurses and staff.
Affect – Her affect labile, and the patient is easily triggered to having an irritable affect.
Appropriateness – The patient’s mood and emotions were congruent with each other, and she went from moments of calm to moments of anxious and agitated.

Motor

Speech – AK spoke with pressured speech with some increased rate. She was disorganized and illogical in her word content. Her volume was loud and harsh.
Eye Contact – Patient maintained appropriate eye contact throughout the interview.
Body Movements – The patient was pacing the CPEP floor while doing the interview. She had no abnormal or unintentional movements.

Reasoning and Control

Impulse Control – The patient displayed impaired impulse control, and aggression.
Judgment – Patient displays an impairment in judgement as seen by her responses to the internal stimuli. She is convinced that her delusions about her husband and the TV are true.
Insight – Patient displayed poor insight as she is convinced that her delusion is true. She understands she is bipolar, but does not see how she is in the wrong.

Differential Diagnosis

Bipolar disorder with psychotic features – Considering patient has a past medical history of Bipolar tpe 1 disorder, she is often seen fluctuating between manic and depressed episodes. Patient is very aggressive and agitated to her husband and the CPEP staff, exhibiting manic symptoms. She is also having very fixed delusions that her husband has been cheating on her showing strong jealousy delusions. She is also having grandiose delusions thinking she is a famous celebrity. Finally, she is having ideas of reference delusions, thinking that people from a TV show are talking about her and her husband. This is showing psychosis symptoms. Finally, the next morning, patient is very calm and nonaggressive, exhibiting her bipolar lows.
Delusional disorder– Delusional disorder is when one exhibits delusions for over a month without psychotic symptoms. Patient has fixed false beliefs that her husband is cheating on her, that she is famous and that people in the TV are talk about her. This means the patient is displaying delusions of jealousy, grandiosity, and ideas of reference. This has also been going on for a while, as the patient was recently seen in the psych department for the same complaint. She is not complaining of any hallucinations, but does have a history of bipolar disorder.
Schizoaffective disorder– Schizoaffective is when a patient has symptoms of schizophrenia with an underlying mood disorder for over 2 weeks. She has been showing positive signs such as delusions for over 2 weeks, and is diagnosed with bipolar disorder that is currently not managed with medication. This is unlikely because she is not having any signs of hallucinations or any other aspects of schizophrenia. Patient has also been very aggressive and agitated.
Drug induced psychosis: There are many types of substances that can induce psychotic symptoms such as hallucinations or delusions. However, this is less likely since the patient states that she does not use any substances. But this can not be dismissed until we get the lab results of the drug panel, oxycodone panel, THC level, and amphetamine levels back from the labs.

Diagnosis

Bipolar disorder with psychotic features

Assessment:

45 year old Nigerian female with a past psych history of Bipolar disorder who is domiciled with husband and 3 children and is unemployed, is brought in by EMS secondary to paranoid and aggressive behavior. Upon evaluation the patient is very agitated and is repetitively saying how her husband is cheating on her. She says that she is a famous star, and that people in the TV are talking about her and her husband. She is very delusional and is convinced that her husband has been sleeping with people from the church. When her husband talked to her about it, she ended up being physically aggressive towards him. The patient has poor insight, impulse and judgement. As per past psych history, current presentation, and mental status exam, patient’s diagnosis is most consistent with substance induced bipolar disorder type 1 with psychosis. Patient will be admitted to CPEP for further observation and evaluation.

Treatment Plan:

First admit patient to CPEP for observation and stabilization

Upon initial evaluation, the patient was very agitated and paranoid that her husband was cheating on her, and had to be stabilized. Also considering that the patient has a strong past psych history, she should be observed in a safe environment, rather than being discharged.

Administer Ativan 2mg and Haldol 5mg PO

Upon arrival to CPEP, the patient was very irritable and agitated to the nurses and staff.

The following labs will be ordered:

CBC and BMP: to assess for any signs of anemia or infection. And to check her electrolytes and glucose as she has had decreased appetite.
THC: to check for levels of marijuana in the blood
Urine toxicology: to test for evidence of substance abuse in the urine, such as marijuana, cocaine, amphetamines, PCP and opiates.

Beta hCG/urine pregnancy: Since the patient is 45 and is of child bearing age.
Amphetamine: to asses the level of the substance in the body
Blood alcohol level: Even though the patient states that she does not drink alcohol, it is important to check considering she has a history of using other substances.
Oxycodone urine: to check for levels of oxy in the blood
TSH: to assess levels of thyroid hormone and see if thyroid abnormalities are attributing to her symptoms

Medicine reconciliation: start patient on Risperidone 1mg BID
Start patient on hypertensive meds: amlodipine 5mg PO daily
Maintain regular diet
Keep patient on observation every 15 minutes in order to assess for fluctuations in mood
Continue communication with Collateral (husband) to keep him informed and obtain any new information.

Revaluate in the morning for possible inpatient admission
Discuss psychoeducation as a mechanism of therapy for the patient

Morning Assessment:

Upon evaluation the next morning, the patient was more calm and well-behaved. She slept very comfortably through the night, and ate breakfast. She had no disruptive or aggressive behavior. Patient continuously denied all her accusations from the night before, denying that her husband was cheating or that she was a famous person. She says that “I just want things to go back to normal.” She says she is a good mother and that she would never do anything to harm her children. Patient says she is ready to go home. She denies any suicidal/homicidal ideations or any visual/auditory hallucinations. Patient is to stay on q15 observation, will determine her disposition after evaluating with the physician and speaking to husband if he feels safe for her to come home. She will then have a reevaluation of her medications, and will be educated on the importance of compliance.