H&P #3

Medical ED Psychiatric Consult

 

Patient Identification

Name: J. O.

DOB: xx/xx/1998

Age: 25 years old

Race: African American

Ethnicity: Not hispanic/Latino

Address: Queens, NY

Date/Time: December 5, 2023 9:00 AM

Location: QHC

Source of Information: self, mother

Reliability: reliable

 

Chief Complaint – “I hurt myself” x 5 hours

 

HPI

25-year-old African American female single, employed, domiciled with family (mother and 3 siblings) with no past psychiatric history and no past medical history BIBEMS activated by self for suicidal ideation and s/p suicidal attempt by cutting her left arm. Patient reports her original plan was to “stab herself in the neck” but she first decided to cut herself on arm to see if she could go through with it. Patient states yesterday her and boyfriend broke up due to her “abandonment issues.” Patient states her suicidal ideations began in 2019 and have been persistent since then. She states during this time in 2019 she was going through a difficult time in school and had an abortion. Patient reports poor social support, states she “has no friends” and has a “rocky relationship with family.” Patient reports feeling down and depressed and has a loss of interest in activities. States she feels that “people don’t care about her.” Admits to poor sleep and appetite. Patient states she has never seen a psychiatrist or received any psychiatric treatment.

Collateral information collected from mother, Georgia (xxx-xxx-xxx) who is present at bedside. Mother states she was at home when she saw the ambulance lights and shortly after received a call from her daughter. During call, the patient was hysterically crying to mother. Mother states she is a single mother of 4 and the patient is the 2nd oldest child. Mother reports patient has poor relationship with siblings. Reports that about 1.5 years ago patient threw herself over the banister after a sibling argument. Mother states the patient has “had a lot going on” recently.  Mother expresses safety concerns.

Upon evaluation in MER, patient is AOx3, cooperative, with withdrawn behavior and poor eye contact. Speech is non-pressured with low volume. Patient is tearful during interview. Patient has superficial abrasions to left wrist and forearm. Denies HI/AH/VH. Patient exhibits poor insight, judgement and impulse control. Patient is currently a danger to self and warrants further observation and stabilization in CPEP.

 

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 48): HTN
  • Sister (age 27): No PMHx
  • Sister (age 22): No PMHx
  • Sister (age 18): No PMHx

Social History

  • Living situation: Lives in 3-bedroom apartment in Jamaica with mother and 3 sisters
  • Highest level of education: College
  • Employment: Employed – states she has 2 jobs at airport
  • Relationship status: single
  • Sleep: decreased sleep
  • Appetite: decreased
  • Alcohol: denies use
  • Tobacco: denies use
  • Illicit drug use: denies use
  • Past arrest/incarceration history: none

 

VITALS

BP: 125/80, right arm sitting

Temp: 97.0 F oral

Pulse 78, regular

RR: 16, unlabored

SpO2 96% room air

Weight: 130 lbs

 

MENTAL STATUS EXAM

General

  • Appearance: Average, young African American. She has 17 lacerations (2-3cm in size each) to left arm, non-bleeding, non-infected. Resting comfortably in casual attire. Her hygienic state was clean. Well nourished.
  • Behavior & Psychomotor Activity: No apparent tics, tremors, or fasciculations.
  • Attitude Toward Examiner: Patient was superficially cooperative with examiner, but guarded. Answering questions appropriately when prompted, but with short replies. 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: Flat affect
  • Appropriateness: Her mood and affect were congruent with discussed topics. She did not exhibit angry outbursts. Patient was tearful for short period of interview.

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: Worthlessness
  • Impulse Control: Poor impulse control. Suicidal ideations present.
  • Judgement: No paranoia, bizarre delusions, auditory or visual hallucinations.
  • Insight: Poor insight. Does not appear to appreciate cause/effect and self-defeating/endangering behavior.

 

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—

  1. Suicidal thoughts with method – Have you been thinking about how you might kill yourself? No
  2. 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? No
  3. 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
  4. 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 – High

Risk to others? No

 

DIFFERENTIAL DIAGNOSIS

  • Adjustment Disorder: Adjustment disorder is characterized by maladaptive emotional/behavioral reactions to an identifiable stressor. Adjustment disorder typically begins within 3 months of the stressor. This patient has an identifiable stressor that she identifies as breaking up with her boyfriend.
  • Borderline Personality Disorder: BPD is a type of cluster B personality disorder. The hallmark features include instability of interpersonal relationships, self-image, moods and marked impulsivity. Patient herself identifies a fear of abandonment and unstable relationship with family. The impulsivity is demonstrated by the suicidality and self-mutilation.
  • 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.
  • Schizoaffective Disorder, depressive type: Schizoaffective disorder is characterized by schizophrenia and a mood disorder. Despite meeting the diagnosis of a mood disorder (depression), 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

25 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 self for suicidal ideation and s/p suicidal attempt by cutting her left arm. Patient currently poses a harm to self.

 

Diagnosis – Adjustment disorder with depressed mood / Borderline Personality Disorder

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

 

Plan

  • 1:1 observation w/ suicide precaution
  • Labs: CBC, CMP, Urine tox, POC urine pregnancy, UA, COVID-19
  • Begin on Sertraline 25 mg PO
  • Individual and group therapy
  • Develop safety plan with patient
  • Reevaluate symptoms and vitals in morning
  • Refer to social work to arrange follow up outpatient psychiatry and counseling pending discharge/stabilization