PATIENT IDENTIFICATION

Name: XX

DOB: XX/XX/XXXX

Age: 35 years old

Race: Asian

Address: Queens, NY

Date/Time: 05/22/2024 @2PM

Location: QHC CPEP

Source of Information: Self, Sister

 

CC – “obsessive thoughts” x 3 days

 

HPI

A 35 year old Chinese female, single, domiciled with sister and father, with a history of schizophreniform disorder was BIBEMS (activated by sister) after endorsing obsessive thoughts of giving her sister a check earlier today. Patient admits to feeling anxious and making a list of everyone in the past that has hurt her. She states she was making a list of people that caused her pain, including her father, dean of her university, and her “school friends.” She did not engage in further conversation about what they have done to hurt her. She denies auditory/visual hallucinations, suicidal or homicidal ideations. Denies chest pain, dizziness, headache, SOB.

 

Collateral history obtained from sister, who reported that the patient was high functioning and went to Stuyvesant HS, Comell for undergraduate studies, and NYU medical school when she had first psychotic break along with OCD symptomatology. She was dismissed from medical school for unprofessional behavior including allegedly stalking professors. She was hospitalized in June 2016 for psychosis (hallucinations, accusations). After 8 years, she became progressively non-functional, unable to care for herself, urinating on herself at times, refusing follow up care, not complying with medications. Patient was repeatedly calling sister regarding giving her a check, although this encounter never took place. Patient was just admitted to CPEP last month and only agreed to take Abilify and get discharged home with outpatient follow up. Sister reported that there was no history of self injury or suicidal behavior/ideations nor any violent history. One week prior, the sister and father obtained court ordered guardianship for the patient. 

 

HISTORY

Past Medical History

No past medical history

 

Past Psychiatry History

Anxiety disorder

Obsessive-compulsive disorder

Schizophreniform Disorder

 

Past Hospitalizations 

June 2016 – following abnormal behavior 

 

Medications

Abilify 25 mg tablet

 

Past Surgical History

No past surgical history

 

Allergies

No known drug/environmental/food allergies

 

Family History:

Mother – unknown

Father – alive and well 

Sister – ADD/ADHD

Maternal Grandmother – HTN

Maternal Grandfather – HTN

 

Social History

Living Situation: Lives at home with sister and father 

Highest level of Education: Undergraduate studies, was dismissed from NYU medical school 

Employment: Unemployed

Relationship Status: Single

Sleep: Normal sleep

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

Alcohol: denies use

Tobacco: denies use

Illicit Drug Use: denies use

Past arrest/incarceration history: none

 

VITALS

BP: 123/81 (RA, sitting)

Temp: 97.5 F

Pulse: 83 beats per minute

RR: 18, unlabored 

SpO2: 98% on room air

Weight: 118 lb

 

ROS

General – Denies weakness/fatigue, fever.

Skin, hair, nails – Denies rash, pruritus, excessive sweating.

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, and obsessive thoughts. Denies insomnia, past suicidal attempts, current suicidal ideations, current visual or auditory hallucinations, homicidal ideations, homicidal attempts.

 

PHYSICAL

Patient is a 35 year old female who appears as stated age of 35. Alert and oriented to person, place, and time, well developed, in no acute distress. 

 

MENTAL STATUS EXAM

General

Appearance: Slim Chinese female appears stated age, with short black hair. No scars present on the visualized portions of her body. Appears anxious in the hospital gown. Normal hygiene. 

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

Attitude Toward Examiner: Receptive and engaging in the conversation. 

 

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 inconsistent with level of education. 

 

Mood and Affect

Mood: “Ok” as per patient

Affect: Constricted

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

 

Motor

Speech: Slowed speech.

Eye contact: Inconsistent 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. Appears to understand her psychiatric history.

 

RISK ASSESSMENT

1. Wish to be dead – Have you wished you were dead or wished you could go to sleep and not wake up? No
2. Suicidal thoughts – Have you actually had any thoughts of killing yourself? No

 

—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? No

Risk to others? No

 

DIFFERENTIAL DIAGNOSIS:

• Obsessive-Compulsive Disorder (OCD):

1. 1. 1. The patient has a history of OCD symptomatology and currently exhibits obsessive thoughts about giving her sister a check and making a list of people who have hurt her. These repetitive and intrusive thoughts are characteristic of OCD.

• Schizophreniform Disorder/Schizophrenia:

1. 1. 1. The patient has a documented history of schizophreniform disorder and has had past episodes of psychosis, including hallucinations and delusions. The current obsessive thoughts and the previous psychotic break during medical school suggest that this disorder may still be present or could have progressed to schizophrenia. Given that her symptoms have progressed over the last 8 years, it is likely schizophrenia. 

• Delusional Disorder:

1. 1. 1. The patient’s preoccupation with making a list of people who have hurt her and the accusations made during her previous psychotic episodes indicate the presence of delusional thinking. The lack of hallucinations in her current presentation aligns with this diagnosis, focusing on delusions.

• Major Depressive Disorder with Psychotic Features:

1. 1. 1. Although the patient denies current suicidal ideations, her history of non-functionality, including urinating on herself and refusing care, suggests severe depressive symptoms. The presence of psychosis in the past, combined with the current anxiety and obsessive thoughts, could point towards major depressive disorder with psychotic features.

• Personality Disorder: Borderline Personality Disorder or Schizotypal Personality Disorder:

1. 1. The patient’s unprofessional behavior, alleged stalking, and the chronicity of her symptoms may suggest an underlying personality disorder. Borderline Personality Disorder could account for the impulsive and erratic behaviors, while Schizotypal Personality Disorder might explain the eccentric thoughts and behaviors without clear-cut psychotic episodes.

 

ASSESSMENT/PLAN

A 35 year old Chinese female with no past medical history and a past psychiatric history of schizophreniform disorder was brought in by EMS activated by her sister for obsessive thoughts. Patient is not currently a threat to herself or others. History and psychiatric evaluation demonstrate a diagnosis consistent with schizophrenia and OCD. 

 

Diagnosis – Schizophrenia and OCD

Disposition – Admit to inpatient psychiatric unit

 

PLAN

• Routine Labs CBC, BMP, UA, UTox to rule out possible substance induced psychosis
• Q15 minutes observation
• Risperidone 2mg and clonazepam 0.5mg x 1 dose and reevaluate. 
  • Risperidone given to manage symptoms of schizophrenia.
  • Clonazepam given to provide immediate relief from acute anxiety and obsessive thoughts.
• Inpatient Psychiatric Admission:
  • Due to her history of non-compliance with outpatient treatment, recent psychotic episode, and significant functional decline, inpatient care will stabilize her condition, ensure medication compliance, and monitor for any acute risks.
• Medications:
  • The patient should continue on Abilify (aripiprazole).
  • Possibly start patient on Sertraline (Zoloft) 25 mg once daily, to be taken in the morning. Increase to 50 mg once daily after one week, for OCD and anxiety management. 
• Psychotherapy:
  • CBT for OCD and anxiety management, as well as supportive therapy. 
• Discharge Instructions:
  • Outpatient follow-up plan with a psychiatrist and a therapist
  • Monitoring for any signs of potential self-harm or harm to others.