History

Name: R.M.

Age: 27 years

Race: Black

Address: Saint Albans, NY

Date/Time: 01/23/24, 10:45 AM

Location: QHC

Source of Information: self

Reliability: questionable

Transportation: EMS

CC: 

“Through psychoanalysis I discovered that I have a glioblastoma, skin, colon, blood, bone, kidney, liver and cataract cancer, chronic encephalopathy and neuropathy.” 

HPI:

Pt is a 27 year old  female, domiciled with her father with PPHx of schizoaffective disorder bipolar type, cannabis and alcohol use and borderline personality disorder who presented to CPEP yesterday with complaints of neuropathy, chronic encephalopathy, and multiple forms of cancer. This morning she admits to dizziness and disorientation because she just vomited. Vomit was nonbloody and non-bilious and only happened one time. Pt currently takes haloperidol 10 mg BID and benztropine 0.5 mg nightly but desires a full psychiatric evaluation in order to wean off of these medications. She mentions that she believes the haloperidol is causing many adverse effects. Pt also mentions that she has been sleeping less (abt. 3 hours) and has been eating a lot recently, which is also attributed to various other medical conditions. Pt admits to using marijuana and alcohol “about twice a week.” Currently denies suicidal ideations, homicidal ideations, auditory and visual hallucinations. Pt appears fidgety and hyperactive with an irritable affect.  

Collateral information obtained from father (name) via phone (number). Father states that pt told him that she is going to the hospital, but did not give any reason why. He also mentions that she goes to the hospital frequently because she reads a lot and applies various illnesses to herself. However, he notes that no abnormal findings were ever found in labs. He states that recently pt has been eating a lot of food and has been very “busy.”   

PMHx:

• None
• Up to date on vaccines
• Unknown screenings 

PPHx:

• Schizoaffective disorder bipolar type x unknown years
• Borderline personality disorder x unknown years

Treatment history:

• Unknown 

Past surgical history:

• None 

Family history:

• Unknown
• Denies known family history of diabetes allergies, lung disease, gastrointestinal diseases, disease of urinary tract, or nervous disorders.

Medications:

• Haloperidol 10 mg BID, schizoaffective disorder
• Benztropine 0.5 mg nightly, prophylaxis for extrapyramidal symptoms of haloperidol

Allergies:

• Penicillin allergy, hives
• Dust, itchy throat and dry eyes
• No known food allergies

Social History:

• Living situation: Lives with her dad in an apartment, with no pets
• Highest level of education: Completed high school
• Employment: Unemployed
• Relationship status: Single
• Sleep: Sleeps about 3 hours, feels rested 
• Appetite: Increased, which pt attributes to various medical conditions (pregnancy, gut parasites etc.)
• Alcohol: Occasionally, about twice a week
• Tobacco: Denies use
• Illicit drug use: Occasionally marijuana, no other illicit substance use 
• Past arrest/incarceration history: None

Substance Abuse History:

• None

Review of Systems:

• General – Denies fatigue, recent weight loss or gain, loss of appetite, generalized weakness, fever or chills, and 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 – Admits to vomiting once. Denies intolerance to specific foods, nausea, 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 –Admits to dizziness. 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 – Denies feelings of depression, mania, OCD, suicidal/homicidal ideation, auditory and visual hallucinations and insomnia.

Physical

General:

• 27 year old non-binary biological female, A&O x3, well developed, well nourished in no acute distress. Appears older than stated age, with poor grooming and hygiene. Pt seemed irritated.

Vitals:

• BP: 120/78, right arm sitting
• Temp: 98.2 F, oral
• Pulse: 74, regular rate and rhythm
• RR: 18, unlabored
• SpO2: 98% room air
• Height: 5 feet 5 inches
• Weight: 143 lbs
• BMI: 23.8 kg/m2

Mental Status Exam:

• General
  • Appearance: Average weight black female, appears older than stated age of 27 with poor hygiene. No scars on her 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 answered questions when prompted. Once pt was irritated by the provider, she became less cooperative. 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: Mood and affect were congruent with discussed topics. She did not exhibit angry outbursts or uncontrollable crying.
• Motor
  • Speech: Clear, non-pressured speech. Normal in tone and speed, with periods of increased tone.
  • Eye contact: Pt maintained eye contact and oftentimes stared at the interviewer. 
  • Body movements: Body posture and movement is appropriate without psychomotor abnormalities noted.
• Reasoning and Control
  • Thought Content: Tangential 
  • Impulse Control: Poor impulse control, with irritable responses to any repeated question
  • Judgment: Exhibits adequate judgment. No active auditory or visual hallucinations, delusions or paranoia.
  • Insight: Poor insight, with belief that the medication is causing more harm than good.

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, bipolar type with current manic episode
  • Pt has a previous diagnosis of schizoaffective disorder and currently is exhibiting signs and symptoms of mania (being “busy,” sleeping less and delusions). 
• Bipolar I disorder
  • In order to diagnose bipolar I disorder, the pt must experience at least 1 manic episode. Mania is characterized by abnormal, expansive, irritable mood for at least one week or less if hospitalization is required. This pt required hospitalization and presents with irritable affect. Additionally pt has decreased need for sleep and is experiencing psychotic symptoms, specifically delusions (somatic delusions). Delusions do not need to be present for diagnosis, but it may be present in severe cases of mania. It is more likely that the pt is having an episode of mania as part of her previously diagnosed schizoaffective disorder. However, I included this differential as she does not have any current auditory or visual hallucinations and it is possible there was a previous misdiagnosis. 
• Borderline personality disorder
  • BPD is characterized by unstable interpersonal relationships, hypersensitivity to rejection and impulsivity. Pts with BPP use rigid classifications and tend to see people as either all good or all bad, this is known as splitting. These pts also exhibit irritable moods. This pt was irritable in affect and also seemed to classify providers as good or bad. When we first walked into the room the pt was conversing with the provider well, however as soon as the doctor asked a question that irritated the pt, she became irritated and did not respond as cooperatively.
• Substance induced psychosis
  • Cannabis can cause symptoms of psychosis including delusions and hallucinations, especially in pts with previous mental illnesses. Utox should be done to rule this out.
• Illness anxiety disorder
  • This is a psychiatric disorder characterized by excessive worry and preoccupation with having a serious medical condition, despite little or no evidence of any illness. Pts with this have anxiety about their health and oftentimes think that regular bodily functions are actually signs of severe illness. Even regalar lab findings and diagnostic imaging does not appease them. This pt seems genuinely concerned and worried that she has these medical conditions. Additionally, normal lab results do not appease them. This may seemingly be the diagnosis but because of the pt’s other signs of mania, these delusions fit more into the diagnosis of Bipolar I.  
• Factitious disorder
  • Factitious disorder involves the intentional exaggeration or feigning of physical or psychological symptoms, with the primary goal of assuming the sick role. Pts with factitious disorder may go to great lengths to produce symptoms, including undergoing unnecessary medical procedures, presenting false medical histories, or manipulating laboratory tests. This pt has not made up any symptoms (instead she just mentions the diagnoses that she thinks she has) or tried to falsify lab results and therefore I do not think this is the most fitting diagnosis.

Assessment:

• 27 year old female with no significant PMHx and PPHx of schizoaffective disorder and borderline personality disorder in CPEP due to bizarre behavior. Pt denies current suicidal and homicidal ideation, auditory and visual hallucinations. Pt states she has various different illnesses caused from current psychiatric medications. Pt presents with irritable affect and is easily angered by the interviewer.

Diagnosis:

• Schizoaffective disorder, bipolar type with current manic episode (with concurrent BPD) 

Disposition:

• Hold in CPEP for observation
• Close observation, Q15 minutes

Plan:

• Vitals Q8 hours
• Schizoaffective disorder, bipolar type with current manic episode
  • Utox, urine Hcg
  • Check CBC, CMP, LFT, blood glucose, lipid panel, prolactin levels and EKG prior to starting risperidone 
  • Monitor as outlined by the drug company
  • Begin risperidone 2 mg PO nightly- titrate up as needed
  • Develop safety plan with patient
  • Reevaluate signs and symptoms in the morning
  • After discharge, outpatient follow up with psychiatry and psychology
  • Discuss with collateral for safe disposition 
• Borderline personality disorder
  • Psychotherapy (dialectical behavioral therapy)