Identifying Information:

• Name: V.B.
• Sex: Female
• DOB: X/X/XXXX
• Date: 4/6/2021, 9:30 AM
• Location: Queens Hospital Center – Comprehensive Psychiatric Emergency Program (CPEP)
• Source of Information: Self and Husband
• Source of Referral: Husband
• Mode of Transportation: Husband, private vehicle

Chief Complaint: “People are threatening me and my family”

History of Present Illness:

V.B. is a 54 y/o Brazilian female, married and domiciled with husband, unemployed, with a psychiatric history of post-traumatic stress disorder and paranoid schizophrenia and no past medical history, who presents to CPEP brought in by husband complaining of fear for her safety. She states she is being threatened through the computer and phone and reports that no one believes her. She states that her electronics are hacked, and that these people are listening to her conservations and plotting evil plans. Patient states they are very dangerous people and therefore cannot name them. She reports it is “beyond terror.”  She reports these people are following her and planning on killing her and her family. Patient states she cannot discuss the underlying story of who is threatening her because “it would take a week.” She states it is somewhat similar to the storyline of The Terminator but “instead of machines it is humans.” Patient reports she was diagnosed with “psychosis” in the past. She was seen in CPEP in December 2020 with similar thoughts. She states that “no medications will help because I live in a horrible reality.” She states she does not take her medication because she does not have a psychiatric illness but was prescribed a 3-month supply of Clonazepam (Klonopin) for anxiety by a psychiatrist in the past. She denies suicidal ideations, intent, plan or attempts. Patient also denies homicidal ideations, visual hallucinations or auditory hallucinations. She states she has two adult children who live in a different state, but she does not contact them because of threats by people to them as well.

Upon initial evaluation in CPEP, patient is alert, oriented and cooperative but does not want to provide more information on the “dangerous people.” She is anxious with a constricted affect. Patient has poor insight and judgement with persecutory delusions.

Per the patient’s husband J. (###-###-####), the patient has an increase in fear and reports worsening of her symptoms in the past month. He confirms that the patient does not take her medication because she does not believe she needs them but has taken Invega and Klonopin in the past. He also states she has not been eating or sleeping. Husband states that the patient and him are moving to a new apartment in a different borough and are currently in a temporary apartment. He states the patient is more fearful since moving and constantly worries about people trying to harm them. Husband also reports that the patient watches YouTube, which worsens her fears, and has had a worsening of her condition since August 2020. He states the patient had a traumatic childhood with parental abuse and neglect. Husband reports meeting his wife in Brazil 30 years ago.

Based upon current presentation of delusions, the patient is psychiatrically unstable and requires CPEP admission for psychiatric observation, evaluation, medication and stabilization.

Past Psychiatric History:

• Post-traumatic stress disorder (F43.10)
• Paranoid schizophrenia (F20.0)

Past Medical History: Denies any past medical history  

Past Surgical History: Denies past surgical history  

Allergies: No known drug, food or environmental allergies 

Trauma History: Victim of neglect and abuse as a child

Family history: Patient states she does not know family history

Social and Occupational History:

V.B. is a 54 y/o Brazilian female, married, unemployed with high school degree, domiciled with husband in a private residence. Patient is currently in a temporary apartment with her husband in Queens, with plans to move into an apartment in Manhattan soon. She has a high school degree and is unemployed, but previously worked as a realtor for about ten years. Patient has a history of abuse and neglect by her parents and had to start taking care of herself at age 15 in Brazil. The patient was raped at the age of 14. She has two adult children, ages 37 and 40, who she states live in Michigan. Patient met her husband while he was on vacation in Brazil 30 years ago. Patient states she usually stays home and does housework because of fear of leaving the house. She denies tobacco, alcohol or drug use.

Medications:

Escitalopram (Lexapro)           Take 10 mg tablet by mouth daily

Paliperidone (Invega)              Take 9 mg tablet by mouth daily

Patient is not compliant with her prescribed medications.

Review of Systems:

• General: Denies any fever, chills, fatigue, weakness, unintentional weight loss or weight gain, or changes in appetite
• Skin: Denies pruritus, discolorations, rashes, lesions, masses or scarring
• Neurology: Denies headaches, loss of consciousness, history of head trauma or injury, unsteady gait, or any unintentional body movements
• Psychiatric: Persecutory delusions. Denies any auditory or visual hallucinations. Denies suicidal or homicidal ideations, plan, or intent.

Vital Signs:

• Blood Pressure: 115/76 right arm sitting
• Heart Rate: 68 bpm, regular
• Respiratory Rate: 18 breaths/minute, unlabored
• Temperature: 98.2 F orally
• Oxygen saturation: 98% on room air
• Height: 5 feet 0 inches
• Weight: 93 pounds
• BMI: 18.20 kg/m²

Physical Exam:

• General: Alert and oriented to person, place and time. Casually groomed. Cooperative but anxious. Sitting on bed comfortably.
• Skin: No masses, lesions, rashes, discolorations or excoriations. No evidence of intravenous drug use, self-inflicted wounds, or skin-picking. No excessive sweating or dryness noted.
• Head and Neck: Pupils equal and round. No neck masses or signs of trauma.

Mental Status Exam:

• General:
  • Appearance: Slim Brazilian female with black medium length hair, in CPEP attire. Small build. Casually groomed with good hygiene. Appears her stated age. No obvious scars or injuries.  
  • Behavior: Laying down in bed with sheets over her body and head prior to examination.  Appears hypervigilant. Does not appear to have any tics, tremors or psychomotor retardation.
  • Attitude toward examiner: Cooperative but guarded, answering questions, except will not go into detail when further questioned about the people threatening her. Has good eye contact. No hostility or aggression toward examiner or staff.
• Sensorium and Cognition:
  • Alertness and Consciousness: Alert and conscious throughout entire interview. 
  • Orientation: Oriented to person, place and time
  • Concentration and Attention: Impaired attention and concentration. Patient had to be occasionally redirected.  
  • Visuospatial Ability: Normal visual perception with appropriate balance, normal gait and purposeful body movements as seen previously from CPEP triage to private room. Maintained eye contact with examiner and staff.
  • Capacity to Read and Write: Average reading and writing ability displayed by reviewing and signing of documents.
  • Abstract Thinking: Poor abstract thinking by interpretation of commonly used English metaphors.
  • Memory: Remote and recent memory appear normal as suggested by her ability to provide recent events leading up to presentation in CPEP.
  • Fund of information and knowledge: Intellectual performance average and consistent with education level and training as displayed with by her vocabulary.
• Mood and Affect:
  • Mood: Patient appears anxious throughout the exam.
  • Affect: Patient had a constricted affect throughout the exam.    
  • Appropriateness: Mood and affect were congruent and consistent with the topics she was discussing. She did not exhibit labile affect, uncontrollable crying or anger.
• Motor:
  • Speech: Pattern was normal in rate and inflections. Volume level remained the same throughout.   
  • Eye contact: Maintained eye contact while speaking and listening.
  • Body movements: Appeared calm with purposeful movements. She had no tics, tremors or unintentional body movements. Gait was observed previously while the patient was in the hallway and was normal. Patient remained sitting upright in bed during the exam.
• Reasoning and Control:
  • Thought Pattern/Process: Illogical and disorganized, with some circumstantial thoughts.
  • Thought Content: Persecutory delusions as the patient believes people are threatening and going to harm her and her family. No auditory or visual hallucinations 
  • Impulse control: Normal impulse control as patient was not hostile or agitated. Denies suicidal ideations, plan or intent. Denies homicidal ideations, plan or intent.
  • Judgement: Patient did not have the ability to perceive reality normally and was impaired. She could not make normal decisions as she has persecutory delusions. She did not have auditory or visual hallucinations.   
  • Insight: Poor insight as the patient did not believe she has a psychiatric illness and does not believe that taking medications would change the reality of which she is living.

Assessment:

54 y/o Brazilian female, married, domiciled with husband, unemployed, with no PMHx and prior psychiatric history of PTSD and paranoid schizophrenia. Patient was brought in by husband because of worsening delusions. Patient denies suicidal ideation, homicidal ideation, auditory hallucination or visual hallucination. Patient appears anxious and delusional and is in need of further psychiatric observation and stabilization.

Differential Diagnoses:

• Paranoid Schizophrenia (F20.0) – The patient has a history of paranoid schizophreniaand currently presents with acute psychosis including disorganized thoughts, paranoia and persecutory delusions. The patient has a constricted affect and is socially withdrawn. Since she has a history and currently presents with at least two of the symptoms necessary for schizophrenia, for over a month, this is the most likely diagnosis. Additionally, these disturbances are affecting her social functioning, as she stays in the house due to her fears. Also, the patient is in the setting of medication noncompliance because she does not believe she has a psychiatric illness.
• Adjustment disorder with anxiety (F43.22) – The patient reported that her and her husband are currently in a temporary apartment until they move to another apartment in a different borough. Her response of fear could be due to difficulty coping with the stress of moving, thus making her worried. This is also less likely as the patient is fearful of her current and future apartment and is afraid that dangerous people can hack the cameras and electronics in any facility.
• Delusional disorder (F22) – Patienthas had persecutory delusions for several months, as she has fears that very dangerous people are trying to harm her and her family. She cannot be persuaded that her belief of people harming her is incorrect. While the patient has delusions, she does meet first rank criteria for schizophrenia, thereby making it the more likely diagnosis. In addition, she has marked impairment of her daily life, which is not often see with delusional disorder.
• Substance Induced Psychosis (F19.951) – Patient denies any substance use during the examination. This is a less likely diagnosis, as neither the patient nor the patient’s collateral information endorsed substance use that can cause psychosis. Additionally, the patient has been having the same delusions for several months. However, it must be excluded with a comprehensive urine toxicology once the patient provides a sample.

Diagnosis: Paranoid Schizophrenia (F20.0)

Treatment Plan:

• Admit to Comprehensive Psychiatric Emergency Program (CPEP) under Mental Hygiene Law 9.40 legal status for observation, stabilization and re-evaluation in the morning as patient is actively having delusions.
• Obtain labs and then review
• Complete Blood Count (CBC) – rule out infectious or other organic causes for the patient’s symptoms
• Complete Metabolic Panel (CMP) – Check for electrolyte abnormalities and assess liver function before administration of antipsychotic medication
• Urinalysis – Rule out infectious causes for symptoms
• Urine Toxicology – Obtain urine for drug screens to check for cocaine, amphetamines, phencyclidine, methadone, benzodiazepine, cannabis and opiate use.
• Blood alcohol level – Assess for alcohol intoxication
• Urine pregnancy
• Review previous chart as needed for a comprehensive understanding of previous symptoms
• Nursing staff should observe the patient every 15 minutes for patient safety
• Perform EKG – Check QT interval
• Contact collateral information again as needed to obtain more of the story and information about the patient’s psychiatric history and baseline status.
• Order medications – Hydroxyzine (Atarax) 25 mg every 12 hours for anxiety and Risperidone (Risperdal) 1 mg two times a day to start for psychotic symptoms 
• Regular diet
• Begin psychoeducation so patient understands the importance of medication compliance for her disorder
• Re-evaluation in the morning to determine whether patient should be placed in extended observation unit (EOU) and whether admission will be warranted.