PATIENT IDENTIFICATION

Name: XX

DOB: XX/XX/XXXX

Age: 19 years old

Race: South Asian

Address: Queens, NY

Date/Time: 06/11/2024 @9AM

Location: QHC CPEP

Source of Information: Self, Brother

 

CC – “I want to get away from my family” x 1 day

 

HPI

19 year old Bangladeshi female, reportedly recently divorced, currently a junior in high school, domiciled with parents and older brother was brought in by EMS (activated by family) after making suicidal gestures earlier today. Patient cut her wrist and made threats to her family. At present, patient states that she is not suicidal but is feeling very depressed and hopeless because her family keeps encouraging her to get married but she does not want to. Patient states that she wants to finish school, live her life, and have her own personal space, adamantly denying thoughts of suicide during interview. Reports that she cut herself because she was feeling anxious. She was trying to make an appointment with a therapist when her mother started rushing her and made her angry. States that she was in CPEP in April after making a suicidal gesture and cutting her wrist after her husband at the time abused her. She is no longer married. She denies auditory/visual hallucinations, suicidal or homicidal ideations. 

 

Collateral information obtained from her brother who states that the patient has a history of becoming upset at her family, making threats to kill herself if a discussion about her life persists. He noticed cuts on her left forearm and found her sitting in a chair with a scarf around her neck. Brother confirmed that she was arranged married to a male for 3 months in NYC who abused her, resulting in an episode of suicidal ideations and self harm in April. He states that she is no longer with this husband anymore and lives with her family. He states that the patient had threatened to jump off a roof in Bangladesh after she was in love with her cousin a year ago, demonstrating three total suicidal gestures in the last year. 

 

HISTORY

Past Medical History

No past medical history

 

Past Psychiatry History

None

 

Past Hospitalizations 

None

 

Medications

None

 

Past Surgical History

None

 

Allergies

No known drug/environmental/food allergies

 

Family History:

Mother – alive and well

Father – alive and well 

Brother – alive and well 

 

Social History

Living Situation: Lives at home with parents and brother

Highest level of Education: High school

Employment: Unemployed

Relationship Status: Single

Sleep: Normal sleep

Immigration History: Country of Origin = Bangladesh, Citizenship = US, Bangladesh

Alcohol: denies use

Tobacco: denies use

Illicit Drug Use: denies use

Past arrest/incarceration history: none

 

VITALS

BP: 103/69 (RA, sitting)

Temp: 97.6 F

Pulse: 66 beats per minute

RR: 18, unlabored 

SpO2: 100% on room air

Weight: 81 lb

 

ROS

General – Denies weakness/fatigue, fever.

Skin, hair, nails – Denies rash, pruritus, excessive sweating. Three superficial, linear, dry abrasions to the left forearm. 

Head – Denies headache, dizziness, denies head trauma.

Eyes – Denies visual changes. 

Nose/Sinuses – Denies congestion.

Mouth/Throat – Denies sore throat, cough.

Neck – Denies pain.

Pulmonary System – Denies SOB, coughing, DOE. 

Cardiovascular System – Denies chest pain, palpitations. 

Gastrointestinal System – Denies loss of appetite, nausea, vomiting, changes in stool. 

Genitourinary System – Denies pain.

Nervous – Denies dizziness, gait disturbances, sensory disturbances, paresthesia. 

Musculoskeletal system – Denies pain.

Endocrine system – Denies excessive hunger/thirst.

Psychiatric – Admits to anxiety, depression. Denies insomnia, past suicidal attempts, current suicidal ideations, current visual or auditory hallucinations, homicidal ideations, homicidal attempts.

 

PHYSICAL

Patient is a slim 19 year old female who appears to be her stated age of 19. Alert and oriented to person, place, and time, appears tearful at interview. Left forearm has 3 superficial, linear, dry abrasions. No discharge, bleeding, or swelling.  

 

MENTAL STATUS EXAM

General

Appearance: Slim South Asian female appears stated age, with long black hair. Linear abrasions present on the left forearm. Appears tearful and sad. Normal hygiene. 

Behavior & Psychomotor Activity: No apparent tics, tremors, or fasciculations.

Attitude Toward Examiner: Receptive and engaging in the conversation, preoccupied with discharge.

 

Sensorium & Cognition

Alertness & consciousness: Patient was conscious and alert throughout the interview.

Orientation: Patient was oriented to the date, place, and time of the interview.

Concentration & Attention: Displayed satisfactory attention, was alert during the entire interview. 

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: “Sad” as per patient

Affect: Appropriate

Appropriateness: Her mood and affect were congruent with discussed topics. She experienced the same emotion throughout the entirety of the conversation.

 

Motor

Speech: Normal speech.

Eye contact: Consistent eye contact throughout the conversation. 

Body movements: Body posture and movement is appropriate.

 

Reasoning and Control

Impulse Control: Appropriate to setting.

Judgment: No auditory or visual hallucinations.

Insight: Fair insight. 

 

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, but not currently.
2. Suicidal thoughts – Have you actually had any thoughts of killing yourself? Yes, but not currently.

 

—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

1. 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

1. 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

1. 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:

• Borderline Personality Disorder 

• The patient has a history of unstable relationships, recurrent suicidal behavior, and emotional instability. Her impulsive behavior (cutting herself in response to anxiety and familial conflicts) and her intense emotional reactions are characteristic of BPD.

• Adjustment Disorder with Depressed Mood

• The patient is experiencing significant distress related to identifiable stressors, including her divorce, familial pressure to remarry, and her current living situation. Her symptoms of depression and suicidal gestures could be a response to these stressors.

• Major Depressive Disorder 

• The patient reports persistent feelings of depression and hopelessness. These symptoms, along with her history of suicidal gestures, self-harm, and a significant stressor (her recent divorce and familial pressures), align with the diagnostic criteria for MDD.

• Post-Traumatic Stress Disorder 

• The patient has a history of abuse from her ex-husband, which could be a traumatic event leading to PTSD. Symptoms such as emotional distress, self-harm, and depression could be manifestations of PTSD triggered by reminders of the traumatic experiences.

• Generalized Anxiety Disorder 

• The patient reports feeling anxious, which led to self-harm. Chronic anxiety, especially in the context of familial pressure and past trauma, might contribute to her overall presentation of emotional distress and self-harming behavior.

 

ASSESSMENT/PLAN

A 19 year old South Asian female with no past medical history or past psychiatric history was brought in by EMS for suicidal gestures and self harm. Patient is currently a threat to herself but not others. History and psychiatric evaluation demonstrate a diagnosis consistent with Borderline Personality Disorder. 

 

Diagnosis – Borderline Personality Disorder

Disposition – Admit to Extended Observation Unit (EOU)

 

PLAN

• Routine Labs CBC, BMP, UA, UTox to rule out possible substance induced presentation
• Q15 minutes observation
• Mirtazapine 15 mg tablet, nightly and reevaluate. 
  • Mirtazapine given due to its effectiveness in treating depression and anxiety, its sedative properties to aid sleep, its rapid onset of action for a patient who is acutely distressed and has a history of suicidal gestures and self-harm.
• EOU Admission
  • Due to her history of suicidal gestures and self harm, recent episode, and significantly depressed state, inpatient care will stabilize her condition and monitor for any acute risks.
• Medications
  • Possibly start the patient on Fluoxetine (Prozac) 10 mg daily, increasing to 20 mg daily after one week if tolerated. 
• Psychotherapy
  • CBT for anxiety and to address depressive and anxiety symptoms, and to develop coping strategies for dealing with familial pressures., as well as supportive therapy. 
• Discharge Instructions
  • Outpatient follow-up plan with a psychiatrist and therapist to monitor the effectiveness of the medication, side effects, and any changes in suicidal ideation or behavior. 
  • Monitoring for any signs of potential self-harm or harm to others.