Microsoft Word – Nick Psych HPI Mid Eval.docx

Nicholas Burney Psychiatry Rotation Queens Hospital Center

Identifying Information:

• Name: A.R.
• Sex: Female
• DOB: 4/8/1979
• Date: 2/15/2021 @ 11:30 AM
• Location: Queens Hospital Center – CPEP
• Source of Information: Self
• Source of Referral/Mode of Transport: Brought in by EMS CC: Agitation, aggression and paranoia History of Present Illness: A.R. is a 41-year-old Guyanese single female, unemployed, domiciled with her parents and two children, brought in by Emergency Medical Services (EMS) activated by Mobile Crisis Unit (MCU) for agitation and aggressive behavior. Patient has a history of Schizoaffective disorder, bipolar type, and depression. She was at the Comprehensive Psychiatric Emergency Program (CPEP) as recently as 2/12/21 after son activated EMS for agitation and aggression, and she has been non-compliant with medication and outpatient services after being discharged with Invega on 2/13/21. During follow up visit on 2/15/21, MCU activated ambulance due to patient’s current presentation of agitation, disorganized thinking, and paranoia. Upon beginning the interview, patient appeared calm and cooperative, but quickly became agitated after several questions and is a limited historian, she denies any knowledge of how she arrived at CPEP. Patient presents with severely disorganized thinking, illogical thought processes, and loose associations with flight of ideas and pressured speech. Patient denies that there is anything wrong with her and insists on calling a lawyer. Patient requires continuous redirection to obtain relevant information. Patient makes claims that, “all medication is contaminated and toxic” and that over the weekend she “had a spinal tap because the doctors are searching for her memory gland”. Patient also maintains that she sleeps well but sometimes wakes up at “2 am, 3 am, sometimes 4 am”. Patient denies any suicidal ideations, homicidal ideations, auditory and visual hallucinations. Patient has no history of drug or substance abuse or violence. Patient has had only one other hospitalization at CPEP in Dec. 2019 for irrational behavior and patient did not follow up to obtain medication. Collateral information obtained from son N*** (xxx-xxx-xxxx) states that the patient was acting bizarre and kept repeating that, “she’s working on her doctorial” at home before he called EMS on 2/12/21. He confirms that patient refuses to take any medication prescribed to her because she believes that it is “contaminated” and will harm her. He also confirms that patient was hospitalized in 2019 for depression and schizophrenia, “but she wasn’t as bad as it has been this week”. Past Medical History:

• Schizoaffective Disorder, Bipolar type (HCC) F25.0
• Depression (F33.0)

Past Surgical History:

No notable surgical history.

Past Psychiatric History:

• Schizoaffective disorder – Diagnosed 2/12/21
• Hospitalization for Schizophrenia and Depression Dec. 2019 at Jamaica Hospital
• Has never fulfilled and picked up prescription for outpatient medication. Allergies: No known drug, environmental, or food allergies. Medications:

• Paliperidone (Invega) 24 hr tablet 9mg – 1 daily
• Haloperidol (Haldol) tablet 5mg – Every 8 hours as needed
• Acetaminophen (Tylenol) 650 mg – Ever 6 hours as needed
• Diphenhydramine (Benadryl) capsule 50mg – nightly as needed
• Nicotine (Nicoderm CQ) 21mg/24 hr patch – 1 patch daily
• Magnesium hydroxide (Milk of magnesia) 30 mL daily as needed Family History: Denies knowledge of any family history of psychiatric disorders. Both children are in good health and there is no family history of substance abuse. Social and Occupational History: A.R. is a 41 year old single Guyanese female, unemployed and domiciled with son and daughter. According to collateral info obtained from son, patient was employed as a phlebotomist at an M.D.’s office previously, but has been unemployed for several years. She has a high school diploma and was a certified medical assistant. Patient was never married and has limited contact with both fathers of her children. She does not currently have an income and receives financial support from her parents and fathers of her children. Patient was born in Guyana and moved to U.S.A. at age 13, along with 2 younger siblings. Patient denies any past and current alcohol and illicit drug use. Denies any history of trauma or abuse. Patient has never been arrested. Review of Systems:

• General – Patient denies constitutional symptoms, fever and unintentional weight loss or gain.
• Skin – Skin appears with no discolorations, signs of intravenous drug use, or masses, lesions or scarring. Appears with good level of skin turgor and mucus membranes appear moist.
• Neurology – Patient denies vision changes, balance issues, confusion.
• Psychiatric – Patient denies depression, anxiety, memory deficits, mood changes. Vital Signs:

• BP: 145/80 right arm, sitting
• Pulse: 83 beats per minute
• Respiratory rate: 16 breaths/minute unlabored

• T emperature: 99.0 F (oral)
• SpO2: 99% (room air)
• Height: 5’3”
• Weight: 165 pounds
• BMI: 29.2 Mental Status Exam: General

• Appearance: Patient is an overweight Guyanese female of short stature, casually groomed with somewhat disheveled hair and clothes. Patient has long black hair worn loosely down to shoulders.
• Behavior and Psychomotor Activity – During the interview, the patient was agitated and appeared paranoid, made excessive eye contact and gestured frequently.
• Attitude Towards Examiner – The patient became verbally hostile and threatened to call a lawyer for keeping her at CPEP. Patient did not respond to most questions asked by the interviewer and continued talking with flight of ideas. Sensorium and Cognition

• Alertness and Consciousness – The patient was alert and her level of consciousness was stable and did not fluctuate during the interview.
• Orientation – The patient was oriented to person, but could not explain how she arrived at the hospital. She was not oriented to place or time.
• Concentration and Attention – The patient was very tangential and frequently changed subjects without answering the question, she needed continuous redirection and often gave illogical answers.
• Visuospatial Ability – the patient displayed good visuospatial ability by guiding herself and interviewer around CPEP to a set of chairs to sit in during interview.
• Capacity to Read and Write – The patient has reading and writing abilities consistent with their level of education.
• Abstract Thinking – The patient demonstrates capacity for abstract thinking by interpreting the idiom “no use crying over spilled milk” to mean “don’t get upset about small stuff”.
• Memory – The patient displays impairment of recent and remote memory, as evidenced by the fact that she could not explain how she arrived at CPEP and could not accurately answer questions about her previous employment history.
• Fund of Information and Knowledge –The patient displayed a good fund of knowledge as evidenced by her vocabulary. Mood and Affect

• Mood – The patient’s mood was labile, the interview started while the patient was calm and euthymic and she quickly became hostile and dysphoric during questioning.
• Affect – The patient had a normal affect and facial expression throughout.
• Appropriateness – The patient’s mood was congruent with her emotions and changed from calm to hostile as the patient became agitated. Motor

• Speech – The patient spoke with pressured speech with increased rate. Her volume increased as she became agitated, she was found shouting into the phone at her son after the interview.
• Eye Contact – Patient maintained excessive, menacing eye contact.
• Body Movements – The patient began the interview sitting in a chair, and became agitated and started pacing the floor and gesturing while speaking. No abnormal tics and tremors appreciated. Reasoning and Control

• Impulse Control – The patient displayed poor impulse control by becoming hostile and agitated, and later explosively angry during a phone call to her son.
• Judgment – Patient displays poor judgment as evidenced by her illogical thoughts and inability to perceive reality. Patient believes she had procedures such as a “spinal tap” over the weekend that did not occur.
• Insight – Patient displayed poor insight into her condition by refusing to take any medication, and refusing to acknowledge there was anything wrong with her mental state. Differential Diagnosis

• Schizoaffective Disorder, Bipolar type – Patient displays psychotic features and irrational behavior typical of schizophrenia. The patient also has a history of depression and is now displaying manic characteristics as evidenced by pressured rambling speech, flight of ideas and loose associations between concepts.
• Bipolar Disorder Type 1 – Patient displayed manic characteristics as explained above, as well as having a history of depression. It may be hard to distinguish between normal agitation during a manic episode and psychosis due to schizophrenia/schizoaffective disorder.
• Substance Use Disorder – Substances like cocaine can induce a state similar to mania with grandiose delusions, pressured speech, and paranoia. However, the patient has had no history of substance use disorder. Diagnosis

• Schizoaffective Disorder, Bipolar Type

Treatment Plan:

• Patient will be admitted to psychiatric inpatient services under 9.39, as she poses a danger to herself or others.
• Administer Haldol 5mg as needed every 6 hours to treat acute psychosis and agitation.
• Order CBC, CMP, urine toxicology to rule out substance abuse and electrolyte disturbances.
• Begin Invega 9mg once daily for disease remission.
• Begin Benadryl 50mg once daily to promote restfulness and prevent extrapyramidal side effects.
• Reassess patient in the morning. Morning Assessment:

Reviewing provider note suggests patient appeared calm, euthymic, and cooperative with questioning. She was sitting up in bed and eating breakfast. Patient reports that she slept “sort of good” but still appears highly disorganized with illogical thoughts and delusions. Patient states that, “my son heard me talking this morning and being abrupt-ful”. Patient was being compliant with medication according to nurse. She currently remains psychiatrically unstable and will remain inpatient until she improves. A mood stabilizer will likely be administered as well in order to prevent manic symptoms from recurring.