Identifying Information:

• Name: S.A.
• Sex: Male
• DOB: X/X/XXXX
• Date: 4/15/2021, 2:30 PM
• Location: Queens Hospital Center – Comprehensive Psychiatric Emergency Program (CPEP)
• Source of Information: Self and Wife
• Source of Referral: EMS
• Mode of Transportation: EMS

Chief Complaint: Bizarre behavior in restricted area of airport yesterday

History of Present Illness:

S.A. is an 82 y/o Russian male, domiciled with wife, retired but previous computer programmer, with no known past medical history and a past psychiatric history of schizophrenia per wife, who presented yesterday to Medical Emergency Room by EMS after being found in the restricted area of the airport. Patient was evaluated by the Medical ER team, had a mini-mental status exam of 25 and was “medically cleared” despite no further workup with labs or a CT head. Upon psychiatric consult in the medical ER, patient states he is “alright” and that “nothing happened to me.” He reports about a catastrophe and states he had to go to the airport because of it but denies having a ticket for a flight. Patient reports “I went through the emergency exit at the airport. They captured me and offered that I am either arrested or sent to a psychiatric hospital. I asked to be arrested and they sent me here.” Patient states he sleeps well and denies feeling hopeless or helpless. He denies suicidal ideations, homicidal ideations, auditory hallucinations and visual hallucinations.

Upon initial evaluation in Medical Emergency Room, patient is alert and oriented to person, place and time with slow responses, paranoid and cooperative to most questions, except when questioned further about the “catastrophe.” Patient has poor insight and judgement with nihilistic delusions.

Per the patient’s wife S. (###-###-####), the patient has seen a psychiatrist in the past, in the 1980s, and was prescribed Thorazine and Haldol for schizophrenia at that time. She states the patient has not been on those medications since the 1980s. Wife states the patient has had odd thoughts in the past, including years ago, and states that currently “everything is mixed up in his head.” She states that in the past month, the patient has gone out late at night on three occasions and she has had to call the police to help locate him. Wife states the patient has gone to JFK airport to try to leave or goes to the beach and is waiting for a ship because he believes the Earth is going to collapse and everyone has to evacuate. She states these symptoms have been worsening since January 2021 but denies any trigger to worsen the symptoms. Wife states the patient has conversations with people who aren’t there and when he is told that, he becomes upset. She states he stopped going to doctors five years ago because they thought he was crazy. Wife states that yesterday the patient took a suitcase, took money and went to the airport. She states she knew he was going there and confirms that the patient did not have a ticket for a flight. She states he told her she was crazy and that she should come to the airport as well. She also reports he has warned other relatives that they need to be evacuated as well. Wife also endorsed that the patient will sometimes believe he is the Messiah, has cures for many diseases and believes he is “incredibly rich” and will go to banks trying to withdraw large amounts of money that he does not have. She states he does not sleep well. Wife is concerned for the patient and does not believe this is dementia, and believes he needs medication for schizophrenia. Wife also reports that their son had schizophrenia and committed suicide years ago.

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

Upon further evaluation in CPEP, the patient adamantly refused medication. He states the staff is trying to kill him and that he will not take this poison. Patient also refusing any lab work. Patient was seen pacing in the hallway, internally preoccupied, irritable at times and stated, “don’t you know there is a crisis outside?”

Past Psychiatric History:

• Schizophrenia (F20.9)

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: Son committed suicide thirteen years ago.

Family history: Deceased son with a history of schizophrenia, otherwise unknown family history.

Social and Occupational History:

S.A. is an 82 y/o Russian male, married, retired with college degree and previous computer programmer, domiciled with wife in private residence. Patient and wife live in Queens, near the beach. Patient was born in Leningrad (now St. Petersburg), moved to Italy in 1976 and then moved to the United States in 1977 (immigrated from Russia 37 years ago). Wife states the patient had various jobs in the United States such as a computer programmer, electrician and delivery driver, but was unable to maintain employment due to his mental illness and last worked in the 1990s. Per wife, patient stopped working at 50 years old and stayed home with their son. Patient had an adult son, who had schizophrenia and committed suicide 13 years ago by jumping out of a window on their fifth-floor apartment. Per wife, patient reads a lot when he is home and reads medical papers in his free time. Patient and wife deny that the patient uses tobacco, alcohol or drugs.

Medications:

Patient does not take any current 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: Nihilistic delusions present. Denies any auditory or visual hallucinations. Denies suicidal or homicidal ideations, plan, or intent.

Vital Signs:

• Blood Pressure: 160/80 right arm sitting
• Heart Rate: 88 bpm, regular
• Respiratory Rate: 16 breaths/minute, unlabored
• Temperature: 98.6 F orally
• Oxygen saturation: 97% on room air
• Height: 5 feet 9 inches
• Weight: 153 pounds
• BMI: 22.6 kg/m²

Physical Exam:

• General: Alert and oriented to person, place and time. Casually groomed, wearing glasses. Appears stated age. Cooperative but irritable at times. Sitting on chair in medical emergency room 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 Russian male with sparse grey hair, in yellow gown. Casually groomed with fair hygiene. Appears his stated age. No obvious scars or injuries. 
  • Behavior: Noted to be talking to himself while sitting in chair prior to examination. Appears paranoid. Does not appear to have any tics, tremors or psychomotor retardation.
  • Attitude toward examiner: Cooperative but guarded at times. Irritable and agitated when examiner does not know about the “catastrophe” that is happening. 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 but slow to respond
  • Concentration and Attention: Slightly impaired concentration and attention. Patient had to be occasionally redirected.
  • Visuospatial Ability: Normal visual perception with appropriate balance, normal gait and purposeful body movements seen when patient transferred from medical emergency room to CPEP. 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 his ability to provide recent events leading up to presentation in the emergency room.
  • Fund of information and knowledge: Intellectual performance average and consistent with education level and training as displayed by his vocabulary.
• Mood and Affect:
  • Mood: Patient appears irritable at times throughout the exam.
  • Affect: Patient had a constricted affect throughout the exam.   
  • Appropriateness: Mood and affect were congruent and consistent with the topics he was discussing. He did not exhibit labile affect, uncontrollable crying or anger.
• Motor:
  • Speech: Pattern was normal in rate, tone and inflections. Volume level remained the same throughout.   
  • Eye contact: Maintained eye contact while speaking and listening.
  • Body movements: Appeared calm with purposeful movements. No tics, tremors or unintentional body movements. Gait was observed while the patient was transferred to CPEP. Patient remained sitting upright in chair during the exam.
• Reasoning and Control:
  • Thought Pattern/Process: Illogical and disorganized at times, otherwise patient is goal-directed when speaking to the examiner.
  • Thought Content: Delusional [nihilistic] as the patient believes the Earth has to be evacuated because it is going to collapse. May be responding to internal stimuli. Denies auditory or visual hallucinations 
  • Impulse control: Impaired impulse control as patient would become agitated when questioned about the catastrophe and why he was at the airport. 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, which was evidenced by the patient going into the restricted area of an airport, especially without a ticket. He could not make normal decisions as he has active delusions.
  • Insight: Poor insight as the patient firmly believes that society must evacuate the Earth.

Assessment:

82 y/o Russian male, domiciled with wife, with history of schizophrenia per wife, who was brought to medical emergency room from airport for irrational behavior. Patient is delusional and disorganized with poor impulse control, poor insight and poor judgement and requires CPEP observation.  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:

• Schizophrenia (F20.0) – Patient has a history of schizophreniaper wife over 40 years ago. He currently presents with acute psychosis including nihilistic delusions, paranoia and disorganized and illogical thoughts. The patient is irritable at times with a constricted affect and is seen internally preoccupied, speaking to himself in the chair. He has a history of schizophrenia and presents with psychosis; this is a likely diagnosis. Additionally, the wife states the patient has some type of hallucinations, as he speaks to people who are not present. The patient has been in the setting of medication noncompliance for years. While this is a likely diagnosis, organic causes of these psychotic symptoms must be ruled out as the patient is 82 years old and has not been treated for schizophrenia in over 40 years.
• Dementia with delusions – The patient is older, 82 years old, making him more likely and at risk for dementia. The patient’s past medical history is unknown; therefore, it is unknown if the patient has other risk factors for dementia. The patient’s wife did not recount any episodes of the patient having memory loss or difficulty recalling who she is or any family members. The patient was alert and oriented, able to recall where he was born, how many years he is married to his wife and where he was prior to being in the hospital. Additionally, the patient’s wife did not mention that the patient has difficulty with his activities of daily living. However, the patient does have various delusions including nihilistic and grandiose delusions and is over the age of 65, therefore this should remain on the differential. 
• Organic cause of psychosis – The patient must be ruled out for other organic causes of his psychosis such as a thyroid issue or neurosyphilis. Since the medical emergency room medically cleared the patient without a full workup, an organic cause of his psychosis must be ruled out before a psychiatric diagnosis can fully be established. The patient is currently refusing blood work in CPEP, but if labs and a CT head are never done, an organic cause of the patient’s delusions cannot completely be ruled out, despite the patient’s history of schizophrenia by his wife.  
• Delusional disorder (F22) – The patient has worsening nihilistic delusions for the last four months, as he believes that the Earth is going to collapse, and everyone needs to evacuate. The wife also reported the patient has grandiose delusions, believing he is the Messiah and has the cure to various diseases. These have been occurring for over one month. However, according to the wife, these delusions have been affecting his life for years and he was unable to hold down jobs in his younger years due to his psychiatric illness that was not steadily treated.
• 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: Delusional Disorder

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
• Thyroid Stimulating Hormone – rule out hypothyroidism or hyperthyroidism
• B12 level – rule out B12 deficiency as cause of altered mental status
• RPR – rule out syphilis/neurosyphilis
• 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
• CT head – rule out infectious causes or previous hemorrhage
• 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 – Quetiapine (Seroquel) 25mg for psychotic symptoms, Trazadone 50 mg nightly to aid in sleep, Amlodipine 5mg daily for new hypertension
• Low-sodium diet
• Re-evaluation in the morning to determine whether patient should be placed in extended observation unit (EOU) and whether admission will be warranted – an admission will most likely occur for this patient as he needs more extensive work up and continues to have delusions.