History

Name: P.C.

Age: 37 years

Race: White

Address: Flushing, NY

Date/Time: 01/03/24, 11:30 AM

Location: QHC

Source of Information: self, mother

Reliability: questionable

Transportation: EMS

CC: 

“They implanted a chip in my head when I got my kidney stone removed” 1 year ago. 

HPI:

Pt is a 37 year old male with PMHx of asthma and kidney stone removal and PPHx of schizoaffective disorder, alcohol abuse, cannabis abuse, cocaine abuse, nicotine abuse and opioid (fentanyl) abuse who was brought in by EMS activated by mom due to erratic behavior. Pt is alert and oriented x3 and presents with clear speech, logical thought process with delusions, irritable affect, poor insight and judgment but remained cooperative throughout the interview. Pt states that after receiving kidney stone removal 1 year ago there is a chip in his head that is always watching him. He also mentions that he often sees people watching him, but that they never speak to him. Pt notes that he lost contact with all 4 of his children about 6 years ago, which caused a depressive episode and suicidal ideations at the time. Currently pt does not have any suicidal ideations or thoughts to harm anyone else. Pt states he lives alone, but later his girlfriend came to retrieve their apartment key from him. Pt admits to use of marijuana occasionally, however denies use of alcohol and all other illicit substances. 

Collateral information provided by the patient’s mom, name (number), over the phone. Mom reports that pt was diagnosed with schizoaffective disorder 8 years ago. Pt has been receiving psychiatric care intermittently, but has not been seen by a psychiatrist or taken any medications in the past six months. Mom states that the pt hears voices from his past at night and has recently quit his job after 3 days, claiming that the CIA and FBI are following him. She also notes that he is saying something about a “chip in his head.” Pt was married for 14 years in the past, but then got divorced and has no contact with the 2 children from his marriage. Pt has a current girlfriend, with whom he lives, and their two children were removed from their care. Pt has failed to pay rent for the past year and will be evicted in the next 14 days. Mom says that no outpatient psychiatrist will take new patients immediately and therefore she decided to send him here via EMS. Mom wants him admitted.

PMHx:

• Asthma x32 years, well controlled on meds
• Up to date on vaccines
• Unknown screenings 

PPHx:

• Schizoaffective disorder x 8 years
• Poly-substance abuse x unknown years

Substance Abuse History:

• Alcohol abuse history
• Cannabis abuse history
• Cocaine abuse history
• Nicotine abuse history
• Opioids abuse history

Treatment history:

• Unknown 

Past surgical history:

• Percutaneous nephrolithotomy, 01/2023, Flushing hospital, no complications 

Family history:

• Mother (age 68)- no medical or psychiatric history
• Estranged from father
• No siblings
• Denies known family history of diabetes allergies, lung disease, gastrointestinal diseases, disease of urinary tract, or nervous disorders.

Medications:

• No current medications

Allergies:

• No known drug, food or environmental allergies

Social History:

• Living situation: Lives in an apartment with his fiance.
• Highest level of education: High school
• Employment: Unemployed, after quitting his job due to belief that the CIA and FBI were watching him.
• Relationship status: Engaged
• Sleep: About 7 hours at night, feels rested.
• Appetite: Regular
• Alcohol: Denies use
• Tobacco: Daily
• Illicit drug use: Admits to use of marijuana, but denies use of all other illicit substances.
• Past arrest/incarceration history: None

Review of Systems:

• General – Denies fatigue, recent weight loss or gain, loss of appetite, generalized weakness, fever or chills, or night sweats.
• Skin, hair, nails – Denies changes in texture, excessive dryness, sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.
• Head – Denies headache, vertigo, or head trauma.
• Eyes –Denies glasses, dryness, visual disturbances, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, or pruritus.
• Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
• Nose/sinuses –Denies discharge, epistaxis or obstruction.
• Mouth/throat –Date of last dental exam unknown. Denies bleeding gums, mouth sores, sore tongue, sore throat, or voice changes.
• Neck – Denies localized swelling/lumps or stiffness/decreased range of motion                      
• Pulmonary system – Denies dyspnea, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.
• Cardiovascular system – Denies palpitations, chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.
• Gastrointestinal system – Denies intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, hemorrhoids, rectal bleeding, or blood in stool.
• Genitourinary system – Denies nocturia, frequency, urgency, oliguria, polyuria, dysuria, or flank pain.
• Nervous –Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, changes in cognition/mental status/memory or weakness.
• Musculoskeletal system –Denies muscle/joint pain, deformity or swelling, or redness.
• Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematological system –Denies anemia, easy bleeding or bruising, lymph node enlargement, blood transfusions, or history of DVT/PE.
• Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric – Admits to having a chip in his head and seeing people following him. Denies OCD. feelings of depression or mania, insomnia and seeing a psychiatrist.

Physical

General:

• Overweight 37 year old male, A&O x3, well developed, well nourished in no acute distress. Mildly disheveled with proper hygiene, dressed appropriately for the weather and appears stated age. 

Vitals:

• BP: 125/83, left arm sitting
• Temp: 97.5 F, oral
• Pulse: 91, regular rate and rhythm
• RR: 17, unlabored
• SpO2: 97% room air
• Height: 5 feet 9 inches
• Weight: 200 lbs
• BMI: 29.5 kg/m2

Mental Status Exam:

• General
  • Appearance: Overweight white male, appears stated age of 37 with good hygiene. No scars on his face or hands. Sitting comfortably in a hospital gown.
  • Behavior & Psychomotor Activity: No apparent tics, tremors, or fasciculations.
  • Attitude Toward Examiner: Patient was cooperative with examiner and answering questions when prompted. Displaying respect toward staff members.
• Sensorium and Cognition
  • Alertness & consciousness: Patient was conscious and alert throughout the interview.
  • Orientation: Patient was oriented to the date, place, and time of the interview.
  • Concentration & Attention: Displayed satisfactory attention. Gave relevant responses to questions.
  • Capacity to Read & Write: Patient was able to properly sign name and read.
  • Abstract Thinking: Poor ability to abstract and use deductive reasoning.
  • Memory: Patient’s remote and recent memory appear intact.
  • Fund of Information & Knowledge: Patient’s intellectual performance consistent with level of education.
• Mood and Affect
  • Mood: Anxious
  • Affect: Irritable affect
  • Appropriateness: His mood and affect were congruent with discussed topics. He did not exhibit angry outbursts or uncontrollable crying.
• Motor
  • Speech: Clear, non-pressured speech. Normal in tone and speed.
  • Eye contact: Maintained eye contact.
  • Body movements: Body posture and movement is appropriate without psychomotor abnormalities noted.
• Reasoning and Control
  • Thought Content: Paranoid, linear and goal directed with delusions of persecution
  • Impulse Control: Proper impulse control.
  • Judgment: Exhibits paranoia, bizarre delusions and visual hallucinations. No active auditory hallucinations.
  • Insight: Poor insight. Does not appear to understand his psychiatric history.

Risk Assessment:

1. Wish to be dead – Have you wished you were dead or wished you could go to sleep and not wake up? No
2. Suicidal thoughts – Have you actually had any thoughts of killing yourself? No

• —If YES to 2, ask questions 3, 4, 5 and 6. If NO to 2, go directly to question 6—

3. Suicidal thoughts with method – Have you been thinking about how you might kill yourself? N/a
4. Suicidal intent – Have you had these thoughts and had some intention of acting on them or do you have some intention of acting on them after you leave the hospital? N/a
5. Suicide Intent – Have you started to work out or worked the details of how to kill yourself either for a while you were here in the hospital or for after you leave the hospital? Do you intend to carry out this plan? – N/a
6. Suicide behavior – While you were here in the hospital, have you done anything, started to do anything, or prepared to do anything to end your life? No

• Risk to self? No
• Risk to others? No

Differential Diagnosis:

• Schizoaffective disorder, depressive type
  • Schizoaffective disorder is characterized by schizophrenia and a mood disorder. The patient fits the criteria for schizophrenia, which is further explained below in the next differential. Additionally, he has experienced depressive episodes over his lifetime, most notably when he lost custody of his children. Therefore, it is safe to say that this pt has schizoaffective disorder depressive type. This is true because the symptoms of schizophrenia and the mood disorder of schizoaffective disorder may be present at the same time, but can occur at different times. For this, pt should be started on an SSRI (depression) and an antipsychotic (schizophrenia).
• Schizophrenia
  • To diagnose schizophrenia pts must have at least 2 of the following symptoms for at least 6 months:
    • Hallucinations
    • Delusions 
    • Disorganized speech
    • Disorganized or catatonic behavior
    • Negative symptoms 

These symptoms must interfere with life functioning. This pt fits this criteria. He has delusions of persecution (chip in his head, FBI following him etc.) for the past year and additionally says that he sees people following him (visual hallucinations). Collateral information also confirms previous auditory hallucinations. This all interferes with his work, as he quit his job due to his delusions, and affects his relationship with his children being that they were taken away from him. 

• Substance induced psychosis
  • Drug use can cause symptoms such as visual hallucinations, paranoia and delusions; all of which the pt is experiencing. While the patient denies any alcohol or illicit drug use (other than marijuana), there is still a possibility that his presentation is due to drug intoxication. This is even more possible due to the pt’s history of polysubstance abuse. UTox should be ordered to evaluate for any drugs in the pt’s system.  
• Delusional disorder
  • Delusional disorder is diagnosed when a person has at least one non bizarre delusion for one month or more. Additionally, the patient should not have any of the criteria for schizophrenia (such as hallucinations) or any other psychiatric disorder, medical issue, medication or substance use which would explain the symptoms. This differential is last on my list because the pt does not really meet the criteria. The thought that he has a chip in his head is a bizarre delusion that is not even slightly plausible. He also admits to visual hallucinations, a criteria for schizophrenia, and in order for delusional disorder to be diagnosed the pt must not have any other criteria for schizophrenia. 

Assessment:

• 37 year old male with PMHx of asthma and kidney stone removal and PPHx of schizoaffective disorder, alcohol abuse, cannabis abuse, cocaine abuse, nicotine abuse and opioid (fentanyl) abuse who was BIBEMS activated by mom due to erratic behavior. Pt is experiencing paranoid delusions and visual hallucinations currently but denies current suicidal ideation, homicidal ideation and auditory hallucinations. Pt currently does not evidently pose a threat to himself. 

Diagnosis:

• Schizoaffective disorder, depressive type

Disposition:

• Accept pt to CPEP for further observation and monitoring 
• Close observation, Q15 minutes

Plan:

• Vitals Q8 hours
• Schizoaffective disorder, depressive type
  • Utox- r/o substance induced psychosis
  • CBC, CMP, UA
  • Begin sertraline 50 mg tablet once daily x30 days
  • Begin risperidone 1 mg tablet nightly x30 days
  • Develop safety plan with patient
  • Reevaluate signs and symptoms in the morning
  • After discharge, outpatient follow up with psychiatry 
• Tobacco use
  • Nicotine gum 2 mg once
  • Smoking cessation education
• Asthma
  • Fluticasone inhaler 2 puffs daily (one AM, one PM) x5 days
  • Albuterol inhaler Q4 hours PRN
  • Follow up with pulmonologist as needed