Medical ED Psychiatric Consult

 

Patient Identification

Name: J. O.

DOB: xx/xx/1999

Age: 24 years old

Race: Other

Ethnicity: Hispanic/Latino

Address: Queens, NY

Date/Time: November 13, 2023 10:00 AM

Location: QHC

Source of Information: self, mother

Reliability: reliable

 

Chief Complaint – “I took too many pills” x 12 hours

 

HPI

24-year-old Hispanic female with no past medical history, no past psychiatric history, domiciled with family, current undergraduate student BIBEMS to medical ER activated by mother for ingestion of 12 Tylenol 500mg pills last night at approximately 10pm in an attempt to end her life. Patient states she has been feeling overwhelmed with school due to multiple exams for the past month. Patient currently attends __________ where she has been studying early childhood education, beginning in January 2023, approximately 10 months ago. Admits to poor sleep, fatigue and loss of appetite for the past 3 months. Admits to feeling sad more days than not and these feelings have interfered with her concentration and ability to perform schoolwork and study for exams. Patient reports she previously enjoyed going out with friends or spending time with her siblings but recently has lost interest in doing these activities. States she lives at home with her mother, father and two sisters and reports a good relationship with all of them. Pt currently denes homicidal ideations, auditory and visual hallucinations. Denies previous self-injurious behaviors or prior hospitalizations. Denies illicit drug or alcohol use.

Collateral information provided by patient’s mom *name here* (xxx-xxx-xxxx) who was present in MER. information obtained using interpreter services, ID: xxxx. Mom reports that the patient has recently expressed feelings of being overwhelmed with her exams and not sleeping well but did not elaborate on her symptoms to family. As per mother, patient has been spending more time in bed and sometimes skips meals. Patient’s mother first began noticing the patient’s withdrawal about 2 months ago but states she did not notice the gravity of her symptoms until learning about the pill ingestion last night. Mother reports a stable at home life and admits to a normal amount of family arguments but states that there is a strong family dynamic in the home. Mother expresses safety concerns.

Given the current evaluation, patient is psychiatrically unstable and poses a possible danger to self. Patient seen in the medical ER where she displays poor insight, judgement, and impulse control. At this time, patient will be accepted to CPEP pending medical clearance for further observation and stabilization.

 

HISTORY

Past Medical History

• No past medical history

Past Psychiatry History

• No past psychiatric history

Medications

• No current medications

Past Surgical History

• No past surgical history

Allergies

• No known drug/environmental/food allergies

Family History

• Mother (age 50): no medical hx
• Father (age 53): HTN
• Sister (age 24): asthma
• Sister (age 18): no medical hx

Social History

• Living situation: Lives in 3-bedroom apartment with parents, and 2 sisters (twin sister age 24 & younger sister age 18)
• Highest level of education: Some college
• Employment: unemployed (student)
• Relationship status: single
• Sleep: decreased sleep
• Appetite: decreased
• Alcohol: denies use
• Tobacco: denies use
• Illicit drug use: denies use
• Past arrest/incarceration history: none

 

REVIEW OF SYSTEMS:

• General: Admits to decreased appetite. Admits to fatigue. Denies recent weight loss, fever.
• Skin: Denies rash, IV drug use, self-inflicted wounds.
• Neurologic: Denies headache, speech changes.
• Psychiatric: Admits to decreased sleep. Admits to suicidal ideation. Admits to trouble concentrating. Denies irritability, distractibility, paranoia, delusions.

 

VITALS

BP: 97/65, right arm sitting

Temp: 98.3 F oral

Pulse 76, regular

RR: 18, unlabored

SpO2 98% room air

Height: 5 feet 0 inches    Weight: 101 lbs    BMI: 19.73 kg/m²

 

MENTAL STATUS EXAM

General

• Appearance: Slim young Hispanic female with long brown hair. She has no scars on her face or hands. Resting comfortably in hospital gown. Her hygienic state was clean.
• Behavior & Psychomotor Activity: No apparent tics, tremors, or fasciculations.
• Attitude Toward Examiner: Cooperative with examiner and answering questions appropriately. Displaying respect toward staff members.

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 attentions. Gave relevant responses to 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: Dysphoric
• Affect: Expressionless
• Appropriateness: Her mood and affect were congruent with discussed topics. She did not exhibit angry outbursts or uncontrollable crying.

Motor

• Speech: Soft, non-pressured speech. Normal in tone and speed.
• Eye contact: Avoidant eye contact.
• Body movements: Body posture and movement is appropriate without psychomotor abnormalities noted.

 Reasoning and Control

• Thought Content:
• Impulse Control: Poor impulse control. Suicidal urges present.
• Judgement: No paranoia, bizarre delusions, auditory or visual hallucinations.
• Insight: Poor insight. Does not appear to appreciate consequences of actions.

 

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? Yes
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? – Yes
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

Risk to others? No

 

DIFFERENTIAL DIAGNOSIS

• Major Depressive Disorder: Major depressive disorder is characterized by at least 5 associated symptoms where a depressed mood and/or anhedonia must be present. These symptoms need to occur almost every day for at least 2 weeks. The patient exhibits associated symptoms such as decreased appetite, trouble sleeping, fatigue, thoughts of suicide, etc. In addition, these symptoms cause impairment in social and educational settings.
• Anxiety Disorder: Anxiety disorder is characterized by excessive anxiety and worry for more days than not for at least 6 months. The patient reports worrying about exams excessively which has led to her depressed moods. However, the patient’s main complaints about depressed moods and associated symptoms would make major depressive disorder the more likely diagnosis.
• Adjustment Disorder: Adjustment disorder is characterized by maladaptive emotional/behavioral reactions to an identifiable stressor. The patient began college this year and has identified her exams as a stressor. Adjustment disorder typically begins within 3 months of the stressor, since the patient began college earlier this year, this diagnosis is less likely.
• Schizoaffective Disorder, depressive type: Schizoaffective disorder is characterized by schizophrenia and a mood disorder. Despite meeting the diagnosis of a mood disorder, the patient does not currently exhibit the necessary symptoms for schizophrenia. While the patient does display some negative symptoms (affect flattening), there are no hallucinations, delusions, disorganized speech or disorganized behavior present needed to satisfy the 2+ of the criteria needed to diagnosed schizophrenia.

 

ASSESSMENT/PLAN

24 year-old female patient with no past medical or psychiatric history domiciled with family and current undergraduate student presents to the ED BIBEMS activated by mother for the ingestion of 12 Tylenol tablets last night in the setting of suicidal attempt. History and psychiatric evaluation are consistent with major depressive disorder. Patient currently poses a harm to self.

 

Diagnosis – Major Depressive Disorder

Disposition – accept patient to CPEP pending medical and poison control clearance for further observation and stabilization

 

Plan

• 1:1 observation w/ suicide precaution
• Labs: CBC, CMP, Urine tox, POC urine pregnancy, UA, COVID-19
• Imaging: EKG
• Begin on Lexapro 10mg tablet QD
• Individual and group therapy
• Develop safety plan with patient
• Provide patient education on depression
• Reevaluate symptoms and vitals in morning
• Refer to social work to arrange follow up outpatient psychiatry and counseling pending discharge/stabilization