Identifying Information:

–   Name: L.H.

–   Sex: Female

–   DOB: X/X/XXXX

–   Date: 4/21/2021, 9:30 AM

–   Location: Queens Hospital Center – Comprehensive Psychiatric Emergency Program (CPEP)

–   Source of Information: Self and Boyfriend 

–   Source of Referral: EMS

–   Mode of Transportation: EMS

Chief Complaint: Suicidal ideation and anxiety 

History of Present Illness:

L.H. is a 31 y/o Caucasian female, domiciled with boyfriend, employed, with a past medical history of polycystic ovarian syndrome, alcohol-induced seizures and a reported past psychiatric history of bipolar disorder, depression, anxiety, panic disorder, polysubstance abuse and borderline personality disorder, brought in by EMS activated by therapist, presented to CPEP for suicidal ideation. Patient was previously in the medical emergency room with a blood alcohol level of 140 mg/dL and was brought to CPEP once she was clinically sober. She states “I don’t see a purpose in living. I have nothing to live for. I have no real job, no family, no friends.” Patient states “I think about death and dying all day long.” She states she has had intrusive thoughts of suicidal ideation for two years. She states she has had previous suicidal attempts by cutting her wrist, and states she recently cut her wrist to “feel something.”  She admits to feeling hopeless, helpless and reports difficulty concentrating and anhedonia. Patient also reports her anxiety has been worsening for several months, especially since the beginning of the pandemic. She states she has had “severe anxiety” for several years and reports that she has not been prescribed the medication she needs, a benzodiazepine, by her psychiatrist. She reports multiple panic attacks stating she feels she can’t breathe; her hands curl up, she becomes shaky and has bilateral arm numbness that lasts for several hours, almost every day. Patient states CBD cigarettes help with her anxiety, but reports she recently relapsed with alcohol and drinks 3-4 hard seltzers a day. She was previously sober for a year, but relapsed because she has no other means to deal with her anxiety. Patient states her boyfriend is threatening to make her leave the house because of her recent alcohol use. She denies any recent major trigger in regard to her anxiety, but reports that not smoking marijuana, loud noises and small spaces are triggers. Patient states she has no quality of life because she is “scared of everything.” She states her psychiatrist has tried Lithium, Mirtazapine, Olanzapine, Seroquel and Zoloft, all of which did not work long-term. Patient reports Klonopin and Ativan have worked but states it will not be prescribed to her. She reports suicidal ideations. She denies homicidal ideations, auditory hallucinations or visual hallucinations at this time.  

Upon evaluation in CPEP, the patient is alert and oriented, cooperative but anxious, tearful and making poor eye contact. Patient answers all questions, but consistently interjects asking when she can be given a benzodiazepine, how much and how often. 

Collateral information collected from the patient’s boyfriend G. (###-###-####). Patient’s boyfriend states the patient is constantly anxious. He states he is concerned for her safety and mental health. He reports that the patient was prescribed Klonopin and Ativan in the past for her anxiety but reports that the psychiatrist discontinued it because she was misusing the medications. Boyfriend states that there is no obvious trigger to her panic attacks. He states the patient becomes aggressive, throws items and cuts herself during these attacks. He reports the patient states she wants to hurt herself until she sees blood, because that is when she feels something. He states he wants her to get help and be on medications that will reduce her symptoms.

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

Past Psychiatric History:

• Generalized Anxiety Disorder (F41.1)
• Major Depression Disorder (F33.1)
• Borderline Personality Disorder (F60.3)
• Polysubstance Abuse (F19.10)
• Bipolar I Disorder (F31)
• Panic Disorder (F41.0)

Past Medical History: Polycystic Ovarian Syndrome, Alcohol-Induced Seizures 

Past Surgical History: Denies past surgical history  

Allergies: Reports Amoxicillin anaphylaxis. No other known drug, food or environmental allergies 

Trauma History: Patient reports she was the victim of rape starting at nine years old and multiple times after that by a kid in the neighborhood. 

Family history: Patient denies any family psychiatric diagnoses as she does not speak to her family. 

Social and Occupational History:

L.H. is a 31 y/o Caucasian female, domiciled with boyfriend of two years, employed with a high school degree. Patient lives with her boyfriend in Queens. She states she has a high school degree and completed one year of college. Patient is currently employed from home and does “digital work” for her friend. She states she previously was a medical assistant but had to stop working as a medical assistant due to side effects of Lithium she was previously prescribed. Patient states she has no quality of life at this time due to her anxiety, as she is afraid to leave the house – she is afraid to take the train because she is scared of a terrorist on the train and then being unable to escape. Patient recently had a relapse with alcohol, drinking 3-4 hard seltzers a day, and was previously sober for a year. She reports marijuana use, but not in several months, and reports cocaine use in the past. Patient also smokes CBD cigarettes regularly. Patient states she has no relationship with her parents and has not spoken with them in years. 

Medications:

Patient is not currently on any 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: Suicidal ideations present but denies intent, plan or attempt. Denies any auditory or visual hallucinations. Denies homicidal ideations, plan, or intent.

Vital Signs:

–   Blood Pressure: 126/79 left arm sitting

–   Heart Rate: 85 bpm, regular

–   Respiratory Rate: 18 breaths/minute, unlabored

–   Temperature: 98.3 F orally

–   Oxygen saturation: 97% on room air

–   Height: 5 feet 1 inches

–   Weight: 123 pounds

–   BMI: 23.3 kg/m²

Physical Exam:

–   General: Alert and oriented to person, place and time. Well groomed. Appears stated age. Cooperative throughout the exam. Sitting upright in bed in CPEP. 

–   Skin: Tattoos to left forearm, covering previous self-inflicted scars. Superficial 1 cm linear self-inflicted cut on left forearm with no erythema, edema or signs of infection.  No masses, lesions, rashes, discolorations or excoriations. No evidence of intravenous drug use 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: Normal build Caucasian female with long black hair. Well-groomed with good hygiene. Appears her stated age. Self-inflicted linear laceration to the left forearm, with previous self-inflicted scars covered by tattoos. 
  •  Behavior: Patient appears restless and intermittently tearful. Does not appear to have any tics, tremors or psychomotor retardation.
  • Attitude toward examiner: Cooperative and answers all questions and answers appropriately. Interjects examiner to ask for benzodiazepines. Has poor eye contact, only looks at examiner occasionally, otherwise looks straight at the wall. No hostility or aggression toward the examiner or staff.
• Sensorium and Cognition:
  • Alertness and Consciousness: Alert and conscious throughout the entire interview. 
  • Orientation: Oriented to person, place and time.
  • Concentration and Attention: Patient isdistractible and inattentive. Primarily concentrated on receiving a benzodiazepine.
  • Visuospatial Ability: Normal visual perception with appropriate balance, normal gait and purposeful body movements seen when the patient was transferred from medical emergency room to CPEP. Poor eye contact with the examiner and staff as she stared at the wall or kept her gaze downward during the interview. 
  • Capacity to Read and Write: Average reading and writing ability displayed by reviewing and signing of documents.
  • Abstract Thinking: Fair 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 the emergency room and CPEP. 
  • Fund of information and knowledge: Intellectual performance average and consistent with education level and training as displayed by her vocabulary.
• Mood and Affect:
  •  Mood: Patient is anxious and dysmorphic.
  • Affect: Patient has a blunted affect. 
  •  Appropriateness: Mood and affect were congruent and consistent with the topics she was discussing. She was tearful at times. She did not have uncontrollable anger. 
• Motor:
  • Speech: Speech was pressured at times. Pattern was normal tone and inflections. Volume level remained the same throughout.   
  • Eye contact: Poor eye contact while speaking and listening, as the patient looked straight at the wall or had a downward gaze during most of the interview. 
  • Body movements: Appeared calm with purposeful movements. No tics, tremors or unintentional body movements. Gait was observed previously while the patient was transferred to CPEP. Patient remained sitting upright in her bed during the exam.
• Reasoning and Control:
  • Thought Pattern/Process: Normal thought pattern and process as the patient was able to logically explain the sequence of events that brought her to the emergency department and answered questions appropriately. 
  • Thought Content: Unimpaired as patient had no auditory or visual hallucinations. 
  • Impulse control: Impaired impulse control as the patient has self-inflicted wound to her forearm with suicidal ideations, but no plan or intent. Denies homicidal ideations, plan or intent.
  • Judgement: Patient’s judgement is impaired as she has self-inflicted wound to her forearm. Also, she was previously intoxicated while in the medical emergency room. 
  • Insight: Patient’s insight appears intact as the patient is aware of her current situation.

Assessment:

31 y/o Caucasian female, domiciled with boyfriend, with a past psychiatric history of anxiety, depression, bipolar disorder, panic disorder, borderline personality disorder and polysubstance abuse, who was brought from the medical emergency room after clinically sober to CPEP for suicidal ideations and anxiety. Patient is anxious with dysmorphic mood and active suicidal ideations requiring CPEP observation. Patient denies homicidal ideation, auditory hallucination or visual hallucination. Patient appears anxious and tearful and is in need of further psychiatric observation and stabilization.

Differential Diagnoses:

• Bipolar I Disorder: Patient has a reported history of bipolar I disorder. She is managed by a therapist and psychiatrist but states she is not on any medication for her bipolar disorder as she either had side effects or the medication was not effective. Collateral information could not be obtained by therapist or psychiatrist, as the patient did not provide a name, and the number given was not a facility she has been seen at yet. The patient is currently with a dysmorphic mood and congruent affect, with active suicidal ideations and a self-inflicted cut to her left forearm. Patient is experiencing hopelessness, helplessness and anhedonia, consistent with a depressive episode seen in bipolar disorder. 
• Major Depressive Disorder: The patient has a history of depression and is not on any medication for depression. She is helpless, hopeless and tearful during the interview. While the patient may be experiencing a depressive episode consistent with her bipolar disorder, this has not been verified by her therapist or psychiatrist, as they could not be contacted, and therefore it is possible the patient has MDD instead without any evidence or history of mania, hypomania or mixed episode. She expressed that these symptoms have been occurring for weeks now, matching the criteria of over 2 weeks for MDD. Additionally, she has over five symptoms needed for MDD including dysphoria, suicidal thoughts, loss of interest in activities, difficulty concentrating and feelings of increased worry. 
• Polysubstance Abuse: Patient has a previous history of alcohol abuse with alcohol-induced seizures and she states she was previously sober for a year prior to relapsing. When the patient was brought into the emergency department she had a blood alcohol level of 141 and endorses that she has been drinking heavily recently to try to help with her anxiety. Patient states her boyfriend has stated he will make her move out of their home if she continues to drink. While she has a job, it appears her current symptoms and alcohol use are causing social and occupational dysfunction at this time. Additionally, she reports to using marijuana and cocaine in the past, but only uses CBD cigarettes at this time. While she reported that the CBD cigarettes “have little THC in them and it wouldn’t even affect me,” she consistently uses this drug. 
• Generalized Anxiety Disorder: Patient has a history of anxiety and currently is very anxious and tearful on examination. Patient reports a history of anxiety. The patient most likely has been having continuous anxiety symptoms for over six months, which does meet the criteria. Additionally, this is occurring in various aspects of the patient’s life and is affecting her daily activity, as she states she does not leave her house often because of her worries. Patient did report difficulty concentrating, restlessness and shakiness, all of which are part of the criteria. 
• Panic Disorder: Patient fits the diagnostic criteria for panic disorder as she has recurrent panic attacks, which occur almost every day according to her. She discussed her concern for future attacks and reports feeling chest pain, arm numbness etc., when these episodes occur. However, the patient does have substance use, so the polysubstance use must be ruled out as the cause of these attacks. While agoraphobia has become a separate entity to panic disorder, she also endorsed anxiety about being in small spaces, such as the subway, with fear of not escaping in the event of a terrorist. 

Diagnosis: Bipolar I Disorder 

Treatment Plan:

o   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 the patient has active suicidal ideations. 

o   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

–        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 – Already assessed for in medical emergency room with a blood alcohol of 141 several hours ago

• 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 information about the patient’s psychiatric history, baseline status and any concerns if the patient was discharged.
  • Order medications – Patient was previously given Ativan 1 mg, Olanzapine (Zyprexa) 7.5 mg and Hydroxyzine (Atarax) 25 mg in the medical emergency room last night. Now the following medications will be ordered: 
    • Lorazepam (Ativan) 1mg – for anxiety every 8 hours 
    • Quetiapine (Seroquel) 25 mg nightly to aid in sleeping 
    • Spironolactone 25 mg PO daily for PCOS 
    • Gabapentin 100 mg PO three times a day for seizures 
  • Regular diet
  • Psychoeducation about the management of her symptoms and the importance of finding a medication that will help long-term. Discussed that benzodiazepines are not a long-term solution. 
  • Discussed that the patient can contact certain facilities that participate in dialectical behavioral therapy, as the patient can benefit from this due to her borderline personality disorder. 
  • Re-evaluation in the morning to determine whether the patient should be placed in extended observation unit (EOU) and whether admission will be warranted.