Patient Identification

Name: K. F.

DOB: xx/xx/1989

Age: 34 years old

Race: African American

Ethnicity: Not Hispanic/Latino

Address: Queens, NY

Date/Time: 11/27/23 8:30 am

Location: QHC

Source of Information: self, mother

 

Chief Complaint – “my mother sent me here” x 1 hr

 

HPI

34-year-old African American female with psychiatric history of bipolar 1 disorder and no significant past medical history, single, unemployed, domiciled alone BIBEMS activated by mother for psychiatric evaluation secondary to agitation. Patient reports that her mother came to her house this morning to look for her brother and when she did not allow her mother to come into the house, her mom called 911. Patient further states that her mother called the police in an attempt to steal the house from her and states her mother is constantly plotting against her and “wants full control of my life.” Patient expresses wishes to leave the country, stating “I do not represent America, I represent St. Peter’s cathedral in Moscow and scream for Christianity with my blue nails and toes.” Patient further states that many of the other patients in CPEP are her old high school classmates. States she does not take any psychiatric medications because she does not need them. Denies illicit drug use or alcohol use, admits to occasional cigarette smoking.

Collateral information received from patient’s mother Phyllis (917-XXX-XXXX). Mother reports that she went to the patient’s house this morning to look for her son (patient’s brother). States that the patient did not let her into her house and was saying bizarre things to her. She reports that she called 911 in an attempt to help look for her son and the NYPD/EMS observed the patient’s behavior and brought the patient to the hospital. As per mother, the patient has been sending her bizarre emails and text messages daily, she reports that the patient continues to say that she is packing up and leaving to London soon. Mother reports that patient is not sleeping well or eating and has lost weight.

Upon psychiatric evaluation in CPEP, patient is disorganized, agitated and aggressive with an irritable mood. Patient is hyperverbal with rapid speech and staring eye contact. Patient exhibits flight of ideas, constantly jumping from one topic to another without any obvious logical connection. Patient is exhibiting paranoia stating that CPEP staff are all vampires and every time is she is brought to the hospital it is during a full moon. Denies SI/HI/AH/VH. Patient is preoccupied with discharge and actively threatening staff stating “stop bringing me here or it won’t be good news for any of y’all.” Patient has poor insight, judgement and impulse control. Patient is currently manic and warrants further observation and stabilization.

 

HISTORY

Past Medical History

• No past medical history

Past Psychiatry History

• Bipolar 1 disorder x 15 years

Medications

• No current medications

Past Surgical History

• No past surgical history

Allergies

• No known drug/environmental/food allergies

Family History:

• Mother (age 66): HTN, DM II, HLD
• Brother (age 29): no PMHx

 Social History

• Living situation: lives in home alone
• Highest level of education: College
• Employment: unemployed
• Relationship status: single
• Sleep: decreased sleep
• Immigration history: country of origin = Jamaica, citizenship = US
• Alcohol: denies use
• Tobacco: denies use
• Illicit drug use: denies use
• Past arrest/incarceration history: none

 

VITALS

BP: 110/66, right arm sitting

Temp: 97.8 F oral

Pulse 98, regular

RR: 18, unlabored

SpO2 98% room air

Weight: 122 lbs

 

MENTAL STATUS EXAM

General

• Appearance: Slim African American female appears stated age, with short black hair. She has no scars on her face or hands. Sitting comfortably in bed in proper and kept attire. Her hygienic state was clean.
• Behavior & Psychomotor Activity: No apparent tics, tremors, or fasciculations.
• Attitude Toward Examiner: F appears agitated with examiners. Not allowing questions to be asked by examiners.

Sensorium & Cognition

• Alertness & consciousness: Patient was conscious and alert throughout the interview.
• Orientation: Patient was oriented to the date, place, and time of interview.
• Concentration & Attention: Displayed satisfactory attention, was alert during entire interview. Did not give proper answers to some questions.
• Capacity to Read & Write: Patient was able to properly sign name and read.
• Abstract Thinking: Proper ability to abstract. Average ability to 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: Angry
• Affect: Mostly expressionless
• Appropriateness: Her mood and affect were not congruent with discussed topics. She exhibited labile emotions from calm to angry at sudden times.

Motor

• Speech: Hyperverbal and pressured, rapid speech.
• Eye contact: Fixed eye contact.
• Body movements: Body posture and movement is appropriate.

 Reasoning and Control

• Impulse Control: Poor impulse control. Anger outbursts.
• Judgement: Exhibits paranoia and grandiose delusion. No auditory or visual hallucinations.
• Insight: Poor insight. Does not appear to understand her psychiatric history.

 

DIFFERENTIAL DIAGNOSIS

• Schizoaffective Disorder: Schizoaffective disorder is characterized by schizophrenia and a mood disorder. The patient meets the diagnosis of a mood disorder and currently exhibits the necessary symptoms for schizophrenia, showing delusion and disorganized speech.
• Bipolar 1 Disorder: Bipolar 1 disorder is characterized by an abnormal or persistently elevated mood for at least 1 week that causes significant impairment or hospitalization. Patient has long history of Bipolar 1 and appears to have a manic episode.
• Bipolar 2 Disorder: Bipolar 2 disorder Is characterized by hypomanic episodes, which are present for 4+ days and are not associated with marked impairment of social functioning. This patient is experiencing impairment of social functioning and requires hospitalization.
• Schizophrenia: The patient meets the diagnostic criteria for schizophrenia, however due to the presence of a mood disorder, schizoaffective disorder is the more likely diagnosis.

 

ASSESSMENT/PLAN

34-year-old female patient with past psychiatric history of bipolar 1 disease, no past medical history single, unemployed, domiciled alone BIBEMS activated by mother for psychiatric evaluation secondary to agitation. Patient exhibits delusions and disorganized thinking. History and psychiatric evaluation are consistent with schizoaffective disorder Patient currently poses a harm to self and others and requires further psychiatric stabilization.

 

Diagnosis – Schizoaffective disorder, bipolar type

Disposition – admit to inpatient service for further stabilization

 

Plan

• Labs: CBC, CMP, Urine tox, THC, Alcohol level, POC urine pregnancy, UA, COVID-19
• Q15 observation
• Individual and group therapy
• Begin on risperidone disintegrating tablet 2 mg