HPI #3 T.M
IDENTIFICATION: T.M.
Sex: F Race: Bengali Nationality: US Age:20 Marital status: Single
Address: N/A Religion: N/A
PCD: N/A Date: 06/24/21
Informant: self Reliability: reliable Referral: self
CC: Bizarre Behavior
20 y/o Bengali female with no reported past psychiatric history, past medical or history of substance abuse, domiciled with family, in 12th grade high school BIBEMS activated by sister due to bizarre behavior. Patient states “I don’t know why I’m here”, and says her sister called 911 because patient was “feeling sick” and throwing up. Patient believes her phone and emails are being hacked because someone wants to take her money. She is tearful and is preoccupied with going home. Patient states she applied to me a member of organization “Bottom Line” where she submitted her Social Security number and after that, she believes that her phone and emails have been hacked. She states has been under extreme amount of stress for the past month and receiving threatening messages that someone will take money from her father’s account.
Upon evaluation patient appears disheveled, has poor eye contact. The speech is pressured, mood and affect both dysphoric – patient is crying and fixating on financial issues, stating “I wanted to be a doctor’s assistant and just wanted to get some practice, but they told me I need to pay $400K to do it, how will may family afford it?”. Patient is preoccupied with discharge. Patient’s thought process is illogical and demonstrates loose associations. She is cooperative but has a very limited insight into her illness. Alert and oriented to time and person only, had to be reminded that she is at Queens Hospital. She denied any active SI/HI.
Writer spoke to patient’s sister Zuvaida (929xxx-7250) who states patient has not been able to eat or sleep for the past 3 days. Sister states patient was very labile – laughing/crying, was not recognizing their mother and the sister, stated their father was dead while he is alive and well. Sister states patient wanted to go outside in the middle of the night and fell and hit her head which prompted the sister to call 911. Both patient and sister deny any family history of mental illness and state this is the first time this happened with the patient.
Since arrival to CPEP, she has refused all oral medication. She was medicated with Haldol 5mg and Ativan 2mg last night due to bizarre behavior, agitated behavior. She refused AM Risperdal despite encouragement.
Based on patient’s presentation she demonstrates signs of acute psychosis, impaired insight and a delusion of persecution, which warrants inpatient psychiatric admission.
Mental Status Exam
General
1. Appearance
Ms.T.M. is a small built young female with long black hair. She appears disheveled but good hygiene. No scars/tattoos/ecchymoses noted on exposed skin.
2. Behavior and Psychomotor Activity
Has a moderate psychomotor slowing, likely due to medication received prior (Haldol 5mg + Ativan 2 mg IM)
3. Attitude towards Examiner
Cooperative. Guarded at first but established rapport in a few minutes
Sensorium and Cognition
1. Alertness and Consciousness: Conscious, alert
2. Orientation: Oriented to time and place only, kept asking where we are
3. Concentration and Attention: demonstrated satisfactory attention but kept interrupting asking “When can I go home?” Easily redirectable.
4. Capacity to read and write: able to read and write with no difficulty
5. Abstract thinking: able to perform simple mathematical calculations to determine her age, onset of symptoms, age of her sister.
6. Memory: normal remote and recent memory. No deficits noted
7. Fund of information and knowledge: Able to participate in the interview appropriately. No signs of cognitive delay. Sister states patient is a valedictorian at her school.
Mood and Affect
1. Mood: Dysphoric, anhedonic. Patient is tearful and is preoccupied with discharge begging the writer to help her go home.
2. Affect: blunted (consider effect of a sedative given earlier)
3. Appropriateness: Mood congruent with affect
Motor
1. Speech: mildly pressured
2. Eye contact: poor
3. Body movements: Slow. No tremors or tics noted
Reasoning and Control
1. Impulse control: adequate. Patient denies any suicidal or homicidal ideations.
2. Judgement: patient demonstrated delusion of persecution stating someone “stood her up” so she ended up here, where she does not belong. Patient is also currently endorsing paranoia.
3. Insight: poor. Patient does not believe there’s anything wrong with her and wants to go home and get ready for her graduation ceremony that she has in 4 days.
DDX:
- R/O medical reasons for AMS: Vitals (O2SAT), Head CT, Utox, UA, CBC, CMP+Mg, TSH
~ Review labs/records
- Psychosis (delusion of persecution and anhedonia, disorganized speech, and behavior)
- Delusional Disorder
The presence of one or more delusions with a duration of 1 month or longer
(patient states the “bottom Line” organization hacked her about a month ago)
- Brief Psychotic Disorder (Brief Reactive Psychosis)
Diagnostic criteria requires the presence of one or more of the following symptoms over a period of at least one day but less than one month, with eventual return to premorbid level of functioning:
- Delusions
- Hallucinations
- Disorganized Speech
- Disorganized or Catatonic Behavior
- Symptoms can NOT be explained by another mental illness, medical condition or substance abuse
Patient states she has been under a lot of stress lately due to graduation and applying to Colleges and trying to get clinical experience so she can apply to a PA school
- Schizophreniform Disorder – does not meet the criteria
Diagnostic criteria require the presence of two or more of the following symptoms over a period of at least one month but less than six months:
- Delusion
- Hallucinations
- Disorganized Speech
- Grossly Disorganized Behavior
- Catatonic Behavior
- Negative Symptoms
- Substance/Medication induced Psychotic Disorder
Ruled out because patient has a negative Utox and states she is not taking any medication
- Anxiety Disorder – diagnosis of exclusion. Patient showed no improvement with Ativan 2mg so not likely
Assessment:
20 y/o Bengali female with no reported past psychiatric history, past medical or history of substance abuse, Head CT with no abnormal findings, negative Utox and normal CBC, UA and CMP presents with a new onset psychosis. Patient is disorganized and demonstrates poor insight and judgement. Patient is not cooperative with taking PO medications and Haldol 5mg/Ativan 2mg showed no improvement to psychosis symptoms. Patient is currently unable to take care of herself and will benefit from an inpatient psychiatry admission observation for stabilization and safety.
Dx: Psychosis Not Otherwise Specified F29
Plan:
- Continue Risperdal 0.5mg – compliance encouraged
- ~ Addresses Sleep
- Admit to inpatient psychiatry
- Continue to monitor, observe for improvement
Progress Note (Metropolitan Hospital)
20-year-old female, a hospital transfer patient from Queens General Hospital, presented with insomnia and bizarre behavior at home. She presents today with severe language impairment, very slow speech, intense eye contact, low speech, barely audible, appears paranoid, reports that she read an article that her 97-year-old father “was hanged” and also read an article that she “stole bitcoins.” She presents as fearful and anxious, thought blocked, low energy/avolition. She denies AH/VH today. Denies SI/HI and denies all substance use. She appears to be fearful of delusional thought content and severely impaired by current psychosis symptoms.
Plan:
- Increase Risperidone to 2mg Q6hrs
- Lorazepam 2mg PRN
- Diphenhydramine 50mg PRN for sleep at bedtime
- Monitor and provide safe environment
- Encourage development and use of adaptive coping mechanisms
- Encourage verbalizing concerns to staff
- Maintain Safety
