History

Name: A.N.

Age: 34 years

Race: Black

Address: Flushing, NY

Date/Time: 01/15/24, 9:30 AM

Location: QHC

Source of Information: self

Reliability: Reliable

Transportation: EMS

CC: 

“My wife betrayed me and I don’t know how to continue on in my life.” 

HPI:

Pt is a 34 year old black male with PPHx of major depressive disorder and cannabis use disorder presented to CPEP yesterday for suicidal ideation and depression after finding out that his wife cheated on him. Pt had a flat affect and refused to communicate yesterday. After beginning pt on Mirtazapine yesterday, pt is communicative with sad affect and tearful expression during evaluation today. Pt has an extensive history of unstable relationships, beginning with his mom. Pt reports being neglected and emotionally abused as a child. As a result, he resorted to drugs and gang activities in adolescence. He states he has tried to remedy his relationship with his mom three years ago, which did not go well. He states that this has exacerbated his depression that he has been dealing with throughout his life. Pt has been suffering from anxiety and lack of self confidence for many years and uses marijuana as a coping mechanism, but denies use of all other illicit substances. He claims to have turned his life around after meeting his wife and having his 2 children and mentions that he is heavily reliant on his wife. During his marriage he decided to forego career advancements to allow his wife to achieve her career goals. Despite his sacrifices for her sake, he mentions that once she reached her goals she began to have an affair with her coworker. The pt saw the text messages shared between his wife and her coworker which included pictures of his children, which he says “broke him.” Pt admits to feeling depressed even before discovering his wife’s infidelity, however finding out that information has worsened these feelings. Pt admitted to current feelings of depression and suicidal ideation (with no plan or intention), with his only will to live being his children. Admits to loss of interest in previous hobbies, trouble sleeping and decreased appetite with marked weight loss. Denies current auditory and visual hallucinations and homicidal ideations. Pt notes that he committed to working on healing himself for his family at the start of the new year and has seen an outpatient psychiatrist who started him on Escitalopram 10 mg about 3 days ago. 

Currently pt is exhibiting signs and symptoms of major depressive episode with passive suicidal ideations and multiple external stressors. Pt presents with sad, depressive, teary affect and requires a higher level of psychiatric care. We will admit for further evaluation and care. Collateral was not able to be obtained.  

PMHx:

• None
• Up to date on vaccines
• Unknown screenings 

PPHx:

• Major depressive disorder

Treatment history:

• Escitalopram x3 days 

Past surgical history:

• None 

Family history:

• Estranged from parents
• No siblings
• Denies known family history of diabetes allergies, lung disease, gastrointestinal diseases, disease of urinary tract, or nervous disorders.

Medications:

• Escitalopram 10 mg daily, depression

Allergies:

• Penicillin allergy, hives
• No known food or environmental allergies

Social History:

• Living situation: Lives in an apartment with his wife and 2 kids (aged 13 and 11), no pets.
• Highest level of education: Completed college
• Employment: Special education
• Relationship status: Married
• Sleep: Restless sleep, tries to sleep but has a hard time falling and staying asleep. Feels tired all the time. 
• Appetite: Decreased, with admitted weight loss over the past few months.
• Alcohol: Denies use
• Tobacco: Denies use
• Illicit drug use: Admits to use of marijuana for anxiety, denies use of other illicit substances.
• Past arrest/incarceration history: None

Substance Abuse History:

• None

Review of Systems:

• General – Admits to fatigue, recent weight loss and loss of appetite. Denies 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 feelings of depression, insomnia and seeing a psychiatrist and therapist. Denies OCD, feelings of mania, auditory and visual hallucinations.

Physical

General:

• Slightly overweight 34 year old male, A&O x3, well developed, well nourished in no acute distress. Well groomed with proper hygiene, dressed in hospital gown and appears stated age. 

Vitals:

• BP: 123/84, left arm sitting
• Temp: 97.8 F, oral
• Pulse: 81, regular rate and rhythm
• RR: 18, unlabored
• SpO2: 96% room air
• Height: 5 feet 6 inches
• Weight: 160 lbs
• BMI: 25.8 kg/m2

Mental Status Exam:

• General
  • Appearance: Overweight black male, appears stated age of 34 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: Adequate 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: Sad/depressed, anxious
  • Affect: Flat affect
  • Appropriateness: His mood and affect were congruent with discussed topics. He did not exhibit angry outbursts or uncontrollable crying, though he did get teary throughout the interview..
• 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: Linear and goal directed with feelings of worthlessness expressed.
  • Impulse Control: Poor impulse control.
  • Judgment: Exhibits adequate judgment. No active auditory or visual hallucinations, delusions or paranoia.
  • Insight: Proper insight with desire to work on himself and deal with his depression and mental health struggles.

Risk Assessment:

1. Wish to be dead – Have you wished you were dead or wished you could go to sleep and not wake up? Yes
2. Suicidal thoughts – Have you actually had any thoughts of killing yourself? Yes

• —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? No
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? Yes
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? – No
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? Yes, moderate risk
• Risk to others? No

Differential Diagnosis:

• Major depressive disorder
  • The diagnosis of MDD requires a depressed mood (which this patient has) for at least 2 weeks. Additionally, the pt must experience at least 5 related symptoms in a 2 week period:
    • fatigue/insomnia/hypersomnia (pt has insomnia)
    • Feelings of guilt/worthlessness (pt feels worthless)
    • Recurring thoughts of death/suicide (pt has suicidal ideation)
    • Significant weight change (pt lost a lot of weight)
    • decreased/increased appetite (pt says he hasn’t been hungry in days)
  • The symptoms must impair daily living and cannot be due to other medical conditions, bereavement or substances. This pt clearly fits this criteria, because he is experiencing at least 5 associated symptoms and it began before he found out about his wife’s infidelity. He even mentioned his resolution to deal with his depression began at the end of December 2023, a few days before finding out about his wife.
• Adjustment disorder
  • Adjustment disorder is when a person has an emotional or behavioral reaction to an identifiable stressor. The reaction can manifest as a depressed mood and it must begin within 3 months of the stressor. This patient may fit the criteria for adjustment disorder because he does have an identifiable stressor within the past three months; finding out that his wife cheated on him. However, since the patient began to have depressive signs and symptoms even before he found out about the infidelity this is not the most likely diagnosis.
• Dependent personality disorder
  • DPD is characterized by dependent/submissive behavior, fear of being alone and difficulty making decisions. Oftentimes, people with DPD will accept poor treatment from partners and peers for fear of abandonment. This pt has a history of poor maternal connection and admits to relying heavily on his wife. He states she pays the bills, takes care of his insurance etc. He also gave up career advancements for the sake of his wife, lending to the diagnosis of DPD in that he is trying to appease other people. Although this diagnosis may be present in this pt, it does not explain his current symptoms of depression.
• Post traumatic stress disorder
  • Diagnostic criteria for PTSD includes symptoms that last for over a month or for a traumatic experience that happened any time in the past. Symptoms generally include intrusions (recollections- dreams- and dissociative reactions- feels like it is happening again). The pt must also experience active avoidance of triggers and have alterations in mood (anhedonia etc.) and alterations in reactivity (sleep disturbances, irritability etc.). The patient has a history of childhood neglect, emotional abuse, involvement in drugs and gang activities, and traumatic events in adulthood (infidelity of spouse). This all may contribute to his insomnia, shame and anhedonia which are all symptoms of PTSD. However, the pt does not experience intrusive symptoms or active avoidance of triggers and therefore this is the lowest differential on my list. 

Assessment:

• 34 year old male with no significant PMHx and PPHx of depression in CPEP due to suicidal ideation and depressed mood triggered by problems in his marriage. Pt denies current homicidal ideation, auditory and visual hallucinations. Pt is experiencing feelings of worthlessness and currently does pose a threat to himself. 

Diagnosis:

• Major depressive disorder

Disposition:

• Admit to inpatient psych unit from CPEP 
• Close observation, Q15 minutes

Plan:

• Vitals Q8 hours
• Major depressive disorder and insomnia
  • Discontinue escitalopram 10 mg
  • Continue mirtazapine 15 mg tablet once daily in the evening x30 days
  • Begin psychotherapy (cognitive behavioral therapy)
  • Develop safety plan with patient
  • Reevaluate signs and symptoms in the morning
  • After discharge, outpatient follow up with psychiatry and psychology
  • Attempt to speak with collateral