04/14/2021
Elmhurst Hospital Inpatient Psychiatry

Identifying Information:

• Name: MG
• Sex: female
• DOB: **/**/2002
• Date: 04/14/2021
• Location: A9 Inpatient Psychiatry – Elmhurst Hospital
• Source of Information – self, mother, sister
• Source of referral/transportation – 911 activated by sister

   

  Chief Complaint: as per sister patient was “missing over 24 hours, came home acting bizarre, maybe on drugs”

  History of Present Illness:

  M.G. is a 19 year old single Hispanic female, unemployed, living with mother and sister in Queens, NY, with past psychiatric history of schizophrenia followed outpatient by psychiatrist and no past medical history, presented to Elmhurst Hospital CPEP via ambulance activated by sister due to bizarre behavior after missing for 24 hours. As per sister and mother, patient was missing from home with unknown whereabouts for about 24 hours, came home acting bizarre, erratic, possibly on drugs. While in CPEP, patient was uncooperative, agitated, aggressive, combative and was sedated with Haldol and Ativan multiple times. Patient has since been admitted to inpatient psychiatry.

  Upon evaluation in inpatient psychiatry, patient noted to be alert and oriented to person and place, with illogical and disorganized thought process, flight of ideas, impaired insight and judgement, intense eye contact and internally preoccupied. Patient was partially cooperative with intermittent agitation and irritability but was redirected successfully. When asked about what happened within the 24-hour period that patient was not home, patient responded “I went to Brownsville yesterday, walked around, wanted the gangs to see me, was looking for an older prostitute, went looking for hospital to lay down, but my grandpa was gone, and home for food.” Patient had disorganized and pressured speech and was unable to answer most questions clearly. Patient appeared internally preoccupied and paranoid but denied auditory/visual hallucinations, feeling targeted/followed, suicidal/homicidal ideation/attempt. Patient denied alcohol, drugs, smoking. While on the unit, patient was sedated with Haldol and Ativan several times after unprovoked erratic behavior with aggression, combativeness, yelling, and targeting of other patients and staff.

  Collateral information provided by mother, who stated that patient has had schizophrenia for about two years, has been treated with long-acting injectable antipsychotics, but probably missed her last injection. Mother stated that patient was doing well last few months but started acting more bizarre, odd and agitated in the past few weeks. Mother stated that when patient returned home, she was speaking in an illogical and bizarre manner and could not be calmed down from erratic and agitated state. Mother believes patient has been using drugs and/or alcohol and non-compliant with injection of antipsychotic, causing present relapse of schizophrenia.

Past Medical History:

• Denies

Past Surgical History:

• Denies

Past Psychiatric History:

• Schizophrenia

Allergies:

• No known drug/environmental/food allergies

Home Medications:

• Aripiprazole ER 400 mg injection q 30 days

Family History:

• Patient denies known family history of psychiatric illness or substance use disorder

Social & Occupational History:

• MG is a 19 year old single Hispanic female, unemployed, living with mother and sister in Queens, NY. Highest level of education is 10th grade. Patient is financially supported by mother. Patient denies any history of violence, arrest, trauma, sexual/physical abuse. Patient denies alcohol, smoking or substance use.

Review of Systems:

• General: Patient denies any fever, chills, unintentional weight loss or gain, changes in

  appetite.

• Skin: patient denies pruritus, discoloration, rashes, lesions, masses or scarring.
• Neurologic: patient denies headaches, loss of consciousness, history of head trauma or

  injury, unsteady gait, seizures.

• Psychiatric: patient denies any auditory or visual hallucinations, suicidal/homicidal

  ideations, plan or intent.

Vital Signs:

• Blood pressure: 95/60 (right arm, sitting)
• Pulse: 100, regular
• Respiratory Rate: 17, regular, non-labored
• Temp: 98.2 F (oral)
• SpO2: 100% (room air)
• Height: 5’3
• Weight: 127 lbs.
• BMI: 22.5
• LMP: patient unable to recall date of LMP

  Physical Exam:

• Skin: no masses, lesions, rashes, discolorations, excoriations. No evidence of IV drug

  use, self-inflicted wounds. No excessive sweating or dryness noted.

• Head/Neck: pupils equal and round. Extraocular movements intact. No neck masses or

  trauma noted.

  Mental Status Exam:

• General

o Appearance: MG is a thin Hispanic female of average height with brown hair. MG appears disheveled, minimally groomed. Intense eye contact.

o Behavior: MG appeared irritable, agitated, disorganized, Cooperative in interview, performing repetitive hand motions throughout interview.

o Attitude toward examiner: cooperative with interviewer.

• Sensorium and Cognition:
o Alertness and Consciousness: Patient is alert with stable level of consciousness.

o Orientation: Patient oriented to person, place only.

o Concentration and Attention: Impaired concentration with need to redirect patient to current question. Patient unable to focus attention on a specific topic for more than a few seconds.

o Capacity to Read and Write: unable to assess patients ability to read and write due to agitation, inattention, disorganized behavior.

o Visuospatial ability: patients visual perception was normal.

o Abstract Thinking: patient had poor abstract thinking with inability to interpret proverbs and use metaphors. Patient unable to contrast and compare similarities and differences. Will reevaluate when patient is not disorganized and agitated.

o Memory: impaired recent recall. Remote memory intact.

o Fund of Information and Knowledge: average intellectual functioning.

• Mood and Affect:

o Mood: angry

o Affect: labile, reactive, agitated

o Appropriateness: mood and affect were congruent

• Motor:
o Speech: pressured speech with rapid rate, increased volume.

o Eye Contact: intense eye contact while speaking and listening.

o Body movements: repetitive motions of hands, otherwise fluid and purposeful body movements. No tics, tremors. Gait and station were normal. Patient remain seated during exam.

• Reasoning and Control:
o Impulse control: Patient has impaired impulse control. Patient appears to be acting on spontaneous impulses without regard for consequences, yelling and targeting other patients and staff when in common areas.

o Judgement: patient has impaired judgement, with history of disappearance for 24 hours, erratic and aggressive behavior, and possibly missing dose of monthly injection.

o Insight: patient has poor insight. Patient refuses to acknowledge that she has a psychiatric condition and only takes some medications after extensive explanation of medication effects, purpose, and necessity.

• Assessment:
o MG is a 19 year old Hispanic female with diagnosis of schizophrenia. Patient was reported to be acting odd and bizarre following 24 hour disappearance. Patient presenting as disorganized, agitated, illogical, with poor insight and poor impulse control. Patient is admitted to inpatient psychiatry for observation and stabilization.

• Differential Diagnoses:

o Bipolar I Disorder: patients presentation aligns with manic episode of bipolar I characterized by erratic behavior over a few days, with disorganized speech and poor impulse control. Patients uncertain need for sleep and mood lability make it difficult to rule in/out a diagnosis of manic episode at this time.

o Schizophrenia: patients presentation is most aligned with a relapse of previously diagnosed schizophrenia. Patient presented with agitation, disorganized behavior and speech, internally preoccupied, appearing paranoid. Patient denies auditory or visual hallucinations at this time but appears to be responding to internal stimuli with poor impulse control and intense eye contact.

o Substance-induced psychosis: Patient denied alcohol and drug use but refused to provide urine and blood samples for toxicology. Presentation aligns with substance-induced psychosis with erratic, bizarre, disorganized behavior and agitation and combativeness; however, patient was previously diagnosed with schizophrenia about two years ago, so this diagnosis is ruled out.

 

• Diagnosis: Schizophrenia
• Treatment Plan

  o Labs

  • Complete Blood Count (CBC)
  • Complete Metabolic Panel (CMP)
  • Urinalysis
  • Urine Toxicology
  • Blood alcohol level
  • EKG – evaluate QT interval
  • Medications

    Aripiprazole 20 mg PO once daily morning
    Clonazepam 1 mg q12 hours
    Haloperidol 5 mg PRN
    Lorazepam 2 mg PRN

    o Ensure calm, safe environment

    o Monitor patient every 15 minutes o Re-evaluate in 24 hours