Rochel Boord
1/16/22
Psychiatry Rotation at Queens Hospital

Identifying Information:

Name: AC
Sex: Male
DOB: xx/xx/2002
Location: CPEP, Queens Hospital Center
Source of Information: Self
Source of Referral/Transportation: EMS

Chief Complaint: Suicidal

History of Present Illness:
19 year old single, Caucasian male domiciled with parents, unemployed and not in school since 18 years old, with reported past psychiatric history of depression since 12 years old. Brought in by EMS fr suicidal and homicidal ideation. Per EMS report “patient called a friend in Salt Lake City reporting desire to kill family/classmates/and self. Friend called patients therapist and Utah, who activated 911”. Patient states he had made a statement about wanting to hurt himself to his friend about 3 weeks ago and never mentioned hurting anyone else. He also reports “I have made such comments in the past, but never acted on it.” He states he has been diagnosed with depression for many years and has not been on any medications for a while now, he also mentioned he has not seen any therapist in 2 years. Patient states he is depressed about not having a job and not being in school, and that he is working on both finding a job and applying to go to a community college. He reports “everything has been blown out of proportion and I have no plan to harm myself or anyone else, and that when I said I want to kill myself, I said I wouldn’t because that would harm my friends and family, meaning they would never get over my death”. He refuses to provide a number for his friend. He admits to loss of appetite, fatigue and difficulty sleeping. He admits to 1 previous episode of cutting his forearm at the age of 12, but has not attempted to harm himself since then. He currently denies any suicidal ideation, current attempts, or plans. He denies homicidal ideation, visual or auditory hallucination.

Collateral information obtained form mother (xxx (718) xxx-xxxx) who reports that the patient has made many comments like these in these in the past (about hurting himself, not others) but has never acted upon it. She reports he minimizes his symptoms at times and she has been trying to get him to be seen in the hospital, but he has refused. She states he has not been trying to find a job or apply for school, but spends most of his time playing video games and self-medicating with marijuana. She is concerned about his mental health and is scared he may finally act on the statements he has made. She also reports he was on Prozac in the past, which helped, but he stopped taking the medication over a year ago and started using marijuana instead.

Currently patient is calm and superficially cooperative with depressed mood. Patient appears to be minimizing his symptoms for discharge. Patient is unpredictable and will need further observation, treatment and stabilization in CPEP.

Past Medical History:
Denies past medical history

Past Surgical History:
Denies past surgical history

Past Psychiatric History:
Admits to depression since age 12.

Home Medications:
none

Allergies:
none

Family History:
Denies family history of any psychiatric disorders

Social and Occupational History:
Patient states he currently is no working or in school, but is looking to work and apply to community college. He states admits to using marijuana daily, denies alcohol use or tobacco use. States was previously hospitalized as a child at age 12 for attempt of suicide via cutting his left forearm.

Review of Systems:
General: Denies fever, changes in weight
Skin: denies recent self-inflicted wounds, intravenous drug use, or skin picking.
Neurology: Denies headache, loss of consciousness, history of head trauma, unintentional body movements.
Psychiatric: Admits to feeling down for a long time and loss of interest in previously enjoyed activities. Denies anxiety. See HPI for further details

Vitals Signs:
BP: 124/71 left arm seated
Heart Rate: 72 beats per minute
Respiratory rate: 18 breaths per a minute
Saturated O2: 98% on room air
Temperature: 97.7 degrees Fahrenheit
Weight: 127 lb
Height: 5 feet 8 inches
BMI: 19.3 kg/m²

Physical Exam:

General Survey: 19 year old Caucasian male, alert and oriented to person, place and time, casually groomed, appropriate speech, superficially cooperative, sad mood with congruent affect. Appears stated age.
Skin: Scar noted on left forearm palmar side measuring approximately 8 cm.
Eyes: Pupils equal, round, reactive to light and accommodations. Sclera white, conjunctiva clear.

Mental Status Exam:
General

Appearance: AC is an average height, slim build Caucasian male, casually groomed, good hygiene, without any apparent wounds or injuries to his face, appears stated age of 19 years old.
Behavior and Psychomotor Activity: AC displayed appropriate behavior, cooperative,  good gait with walk to the chair, seated appropriately, no signs of tics, tremors or psychomotor agitation or retardation.
Attitude Towards Examiner: AC was superficially cooperative and answers all questions. He does not display and hostility or aggression towards the examiner, however he does appear guarded.

Sensorium and Cognition

Alertness and Consciousness: AC remained alert and conscious throughout the interview.
Orientation: AC was oriented to person, place, time and date.
Concentration and Attention: AC was fully attentive and alert throughout the interview.
Capacity to Read and write: AC displays average reading and writing abilities, was able to fill and sign required papers for admission.
Abstract Thinking: AC demonstrated intact abstract thinking, by explaining commonly used English metaphors.
Memory: Remote and recent memory appears impact, as demonstrated by his ability to give his previous history and the events leading up to todays visit.
Fund of Information and Knowledge: ACs intellectual performance was average, consistent with his level of education (completed high school).

Mood and Affect

Mood: AC’s mood was depressed.
Affect: AC’s affect appears sad.
Appropriateness: AC’s mood and affect were congruent throughout the interview

Motor

Speech: AC’s speech had average rate and volume of speech. Fluent and clear.
Eye Contact: AC made adequate eye contact.
Body Movements: AC showed average body movements, did not display signs of tremors or tics. Gait was average speed, with average posture.

Reasoning and Control

Impulse Control: AC’s  impulse control appears satisfactory. Currently does not express any suicidal or homicidal urges.
Impulse Control Remarks: AC denies suicidal ideation, but brought in by EMS for stating desire to hurt himself and others to a friend. 
Judgment: AC currently has fair judgement
Insight: AC has mild insight, he is aware of the problem, but is unable to fully relate the issue with continuing to feel this way. 

Assessment:

AC is a 19 year old Caucasian male, domiciled with parents, unemployed and not in school, with reported past psychiatric history of depression. He was brought in by EMS for suicidal and homicidal ideation. Currently AC is calm and superficially cooperative with depressed mood. Patient appears to be minimizing his symptoms for discharge, further observation in Comprehensive Psychiatric Emergency Program is needed to stabilize and treat AC’s Depression.

Differential Diagnosis:

1. Persistent Depressive Disorder: Being that this patient is an adolescent, he would require 1 year of symptoms of depressed mood for most of the day, for more days than not. He also has poor appetite, insomnia, fatigue. During the past year he has not been symptom free for more than 2 months at a time. He meets criteria for major depression continuously for at least one year.
2. Major Depressive Disorder: The patient has depressed mood, loss of interest in previously enjoyed activities, insomnia, fatigue and recurrent suicidal ideation without a specific plan all in within the same 2 week period. The symptoms cause occupation impairment, is not attributed to substance abuse or another medical condition, he has not had any episodes of mania or hypomania, and does not meet criteria for schizoaffective disorder, schizophrenia, schizophreniform, or delusional disorder. He meets the criteria for persistent depressive disorder, which can include major depressive disorder
3. Bipolar Disorder: This patient has depression, but doesn’t display any episodes of mania or hypomania
4. Cyclothymic Disorder: The patient would need to have multiple episodes of hypomania and episodes of depression. To be diagnosed with cyclothymic disorder the person can’t have criteria for major depressive disorder.  

Diagnosis: Persistent Depressive Disorder

Plan:

1. Admit to Comprehensive Psychiatric Emergency Program (CPEP) for further evaluation, observation and stabilization.
2. Order routine labs: complete blood count, comprehensive metabolic panel, Thyroid Function Test, Urinalysis, Urine toxicology including THC, COVID
3. Start Fluoxetine 20 mg daily
4. Discussed with patient psychotherapy benefits, but patient currently refuses, stating he has been to many therapist and has not gotten along with most of them. Patient was asked to think about it and consider the benefits and risks. Will discuss with patient again in the morning.
5. Re-evaluate in the morning.