H&P 1

Identifying data:

Name: CB

Age: 67 

Sex: Female

Race: AA 

Marital status: single, divorced 

Occupation: unemployed

Address: Jamaica, NY

Date and time: 10/7/21 11:24AM 

Location: Queens Hospital Center, Jamaica, NY, CPEP  

Source: self (unreliable), son (reliable) 

Chief complaint: “the staff is harassing me” X 1 week

HPI: 

67 year-old African American female with past medical history of schizophrenia, domiciled with adult sons in the apartment, brought in by emergency medical services activated by self.  Patient has multiple admissions to Queens Hospital Center inpatient and was last discharged on 9/02/21. Patient claims that the apartment complex staff is harassing her, but unable to say who the staff is. Chart review indicates that the patient called 911 claiming that people came into her apartment in the middle of the night to steal money and papers for her identity. Additionally, she feels paranoid that people are stealing money from her bank account. Patient unable to state which medications she is taking, but from past chart review she takes Prolixin 5mg by mouth and Cogentin 1mg by mouth. Currently the patient continues to have paranoia. Patient states she is feeling okay today, and requests to leave because she “has to go to the bank and pay her storage bill”, patient is concerned she will lose her property if she does not do that today. She did not sleep well last night, “because of the vitamin” her stomach was hurting. She states her memory is fine, mini-mental status exam  score was 25 (unable to complete serial 7s) done 10/7/21. She denies suicidal/homicidal  ideations, auditory, visual hallucinations. She denies illicit drug/alcohol use. 

Writer spoke with a son who stated the patient has been non compliant with medications for about a week and has complained about the apartment staff harassing her and exhibiting paranoid behavior. He lives with her and is concerned about her behavior.  Since her arrival to comprehensive psychiatric emergency room, the patient has been compliant with her medications. 

 On psychiatric evaluation the patient is casually groomed, with good eye contact, she was cooperative with the exam, her mood was anxious, with soft spoken speech. Her thought process is illogical with paranoia, poor insight and poor judgment. She is alert and oriented X3  to person, place, time. 

Past psychiatric history: 

Schizophrenia was diagnosed approximately 30 years ago. Patient take prolixin 5mg by mouth and cogentin 1mg by mouth (non compliant), medication is prescribed by Queens Hospital Center mental health outpatient program. 

Past medical history: denies

Past surgical history: denies

Medications: 

Prolixin 5 mg by mouth for schizophrenia

Cogentin 1 mg by mouth for prophylaxis against side effects of Prolixin 

Allergies: no known allergies to medication, food, environment

Family history: Parents are deceased, and the son does not know any details about their health. Patient has a brother who she is not in contact with. Son denied family history of psychiatric disorders

Social history: 

Marital status: single, divorced

Occupation: unemployed

Habits: son denies use of illicit drugs or alcohol

Sleep: son reports patient usually sleeps well but for the past week she has not been sleeping much 

Living situation: Patient lives with her adult sons who are both healthy and employed

Review of systems: 

Cardiac: denies chest pain, shortness of breath, syncope

Respiratory: denies  cough, shortness of breath 

GI: denies abdominal pain, nausea, vomiting, diarrhea, constipation, change in bowel habits

Urinary: denies dysuria, polyuria

Neurological: denies numbness, tingling, unilateral weakness 

Mental status exam: 

Appearance: average height/weight black female with grey hair, casually groomed, alert and cooperative with the examination. Wearing a hospital gown, no visible scars. 

Behavior: good eye contact, patient is sitting abnormally still with delayed psychomotor activity 

Speech: soft spoken, normal rate, impoverished speech

Mood: anxious as she repeatedly requests discharge so she can go to the bank. 

Affect: flat

Thought process: illogical, loose associations, disorganized. 

Thought content: paranoid delusions, but denies suicidal/homicidal ideations, auditory/visual hallucinations

Cognition: Alert and oriented X3 to person, place, time. Mini mental status score 25 (unable to complete serial 7s), demonstrated good memory both remote and recent with poor ability to abstract. 

insight/ judgement: poor insight, poor judgement, patient is paranoid and medication non compliant

Impulse control: appropriate with no homicidal/suicidal ideation. 

Vitals: 

BP: 124/76, HR: 78 regular, RR: 14 unlabored, T: 97.9 F orally, O2: 99% RA

Brief physical: 

General: in No acute distress, good hygiene, casually groomed

Heart: S1 and S2 auscultated, no murmurs, rubs, gallops

Lungs: Clear to auscultation bilaterally, unlabored respirations 

Abdominal: bowel sounds + all 4 quadrants, abdomen soft and nontender.

Extremities: 5/5 strength bilateral,  in upper and lower extremities 

Assessment:

CB is a 67 year-old African American female who  is acutely psychotic secondary to non-compliance with medications and is a danger to herself and therefore, warrants psychiatric admission for stabilization and observation

Plan:

•  admit to Extended observation unit 
• continue medication- prolixin 5mg PO, cogentin 1mg PO
•  Q15 minute observation
•  psychoeducation
•  re-evaluate in the morning with a repeat mental status examination
• Urine drug screen to rule out drug abuse 

Differential diagnosis: 

1. Acute exacerbation of schizophrenia due to medication non-compliance: this is my most likely diagnosis as the patient has a history of schizophrenia with poor insight, and medication non-compliance and is now showing disorganized behavior and delusions
2. Acute psychosis secondary to drug abuse: this is less likely as the patient has been exhibiting these symptoms for a week, and both herself and son deny drug use, however we will obtain a urine drug screen. 
3. Delusional disorder: she has non-bizarre paranoid delusions which meets criteria for delusional disorder, however this is less likely since the patient already has a diagnosis of schizophrenia, and she exhibits other symptoms of schizophrenia including inability to care for herself and disorganized behavior. 

H&P 2

Identifying data: 

Name: AM 

Age: 19

Sex: Female

Race: Hispanic

Occupation: Student

Address: Queens NY

Date and Time: 10/18/21 10:00 AM 

Location: Queens Hospital Center, Jamaica, NY, CPEP

Source: patient (reliable) 

Chief complaint: patient cut her wrist with broken glass 

HPI: 

19-year-old Hispanic female, St. Johns student domiciled off campus with two roommates, Past psychiatric history of anxiety and mood disorder by history, no past medical history brought in by emergency medical services activated by roommate for cutting her wrist. Patient argued with her roommate, who she says is “her best friend” but lately they “haven’t been getting along”  in anger threw a shot glass against the wall, when she picked up the broken glass used it to cut her left wrist (superficial abrasions). Patient has been depressed “since the summer” when she broke up with her boyfriend “it was a toxic relationship” and quit her job bartending where the manager “abused the staff”. Since not having a job the patient has been experiencing financial issues which she said contributed to her depression and lack of interest in school and finding a job. Patient admits to occasional alcohol usage “much less now since I had alcohol poisoning last summer”, smoking marijauna 1-2 times per week. Denies other illicit drug use. On initial evaluation the patient had a labile mood and was intermittently crying and was determined to be a danger to herself  warranting stabilization in comprehensive psychiatric emergency program (CPEP). 

On re-evaluation today the patient is anxious and tearful, intermittently crying throughout the interview. Patient requests to go home, is future oriented, denies suicidal ideation or any desire to hurt herself. She states she was “just exhausted from all her problems” but now she is hopeful to get back on track. Patient has a new relationship, which she reports to be positive and that her new boyfriend is “very supportive of her”. She plans to go home and stay with her father for a while, instead of her off campus apartment, and is hopeful that his support will help her. She is also starting a new job where she reports the environment is positive at a restaurant in the city. She has reached out to a psychiatrist she has seen previously and plans to follow up with them (she is unable to recall the name) but she has access through the employee assistance program through her mothers work. She also desires to figure out her financial situation so she can finish school as she is “so close” to finishing school. She remains goal and future oriented. Patient denies homicidal/suicidal ideation, auditory/visual hallucinations. 

Writer spoke with the patient’s father, regarding her discharge, who agreed to come pick her up today, and he feels comfortable taking her home and that he can support her. He states he can come pick her up within the hour. 

On psychiatric exam the patient is well groomed, alert, with good eye contact, anxious and sad mood with good insight and judgement. Patient is alert and oriented X3 to person, place, time. 

Past psychiatric history:
Anxiety and mood disorder, self reported, undiagnosed 

Past medical history: denies past medical history 

Past surgical history: denies 

Medications: denies taking medication on a daily basis

Allergies: no known allergies to medications, food or environment

Family history: father had a depressive episode in the past 10 years ago. Denies other psychiatric history. Denies family history of cardiovascular, lung, kidney, thyroid, endocrine disease. 

Social history: 

Marital status: single, currently in relationship with male

Occupation: student 

Habits: denies smoking tobacco, smokes marijauna 1-2 times per week, occasionally drinks alcohol (monthly). Denies use of amphetamines, cocaine, inhalants, hallucinogens, opioids, sedatives

Sleep: sleeps well at night 

Living situation: lives off campus with two female roommates, both other students 

Review of systems

Cardiac: denies chest pain, palpitations, known murmurs

Respiratory: denies shortness of breath, cough, wheezing, hemoptysis 

GI: denies vomiting, diarrhea, constipation, abdominal pain

Urinary: denies dysuria, frequency

Neurological: denies numbness, tingling, unilateral weakness

Reproductive: sexually active with one male partner, reports consistent condom usage

Mental status exam: 

Appearance: slim Hispanic woman, well dressed, well groomed, alert, and cooperative with the interview. Wearing a hospital gown. Two superficial abrasions noted on left forearm. 

Behavior: good eye contact, tearful,  no psychomotor agitation or retardation.

Speech: fluent, goal directed. Normal rate, rhythm and tone.  

Mood: “anxious”

Affect: sad and anxious, congruent

Thought process: logical, goal directed, future oriented 

Thought content: denies suicidal/homicidal ideations, auditory/visual hallucinations

Cognition: Alert and oriented to  person, place and time, appropriate

insight/ judgement: good insight, and good judgement, desires to go home with her father to obtain his support. 

Impulse control: fair, denies suicidal ideation.

Vitals: 

BP: 106/66, HR 88 regular, T 98.2 F orally, RR 17 unlabored, O2 99% RA 

Brief physical

General:  No acute distress, well developed

HEENT: head normocephalic and atraumatic, conjunctival clear.

Cardiac: regular rate and rhythm, S1 and S2 auscultated no murmurs, rubs, gallops

Respiratory: clear to auscultation bilaterally, unlabored breathing

GI: bowel sounds + in all 4 quadrants, abdomen soft, nontender, nondistended

Skin: 2 superficial abrasions on left forearm. No rash, other lesions noted

Musculoskeletal: full range of motion upper and lower extremities  

Assessment:

a 19-year-old hispainci female with past psychiatric history of anxiety and mood disorder by history was evaluated and observed overnight in CPEP after roommate called EMS when a patient used broken glass to cut her wrist after an argument. Patient is observed to be tearful but future and goal oriented with good insight and judgement. She denies suicidal ideation or any desire to hurt herself or others. She expresses desire to work toward goals of getting a job, finishing school and being happy. She does not pose acute danger to herself due to mental illness. She demonstrates the ability to care for herself and has adequate impulse control. She does not warrant further observation and stabilization in CPEP and is stable for discharge. 

Plan: 

• Discharge home to father, who will pick her up
• Lexapro 10 mg 30 day supply 
• Follow up with psychiatrist outpatient 
• Follow up with therapist outpatient  

Differential diagnosis: 

1. Borderline personality disorder: intense unstable relationships, suicidal behavior/gestures, impulsiveness, mood instability
2. Major depressive disorder: low energy since the summer, lack of interest in school, suicidal behavior, hypersomnia
3. Adjustment disorder with depressed mood: recent financial difficulties, and relationship ending along with her symptoms of lack of interest in school, suicidal behavior, low energy