Identifying Information:

Name: CJ

DOB: 10/23/92

Date and Time: November 27, 2020

Location: Queens Hospital Center CPEP

Source of Information: Self, Group home staff

Source of Referral: Group home staff

Mode of Transport: EMS

Ms. CJ is a 28 year old Asian female who is 5 feet 3 inches tall and weighs 148 pounds. Ms. CJ resides at XXX street, in Queens NY 11432.

History of Present Illness:

Patient is a 28 year old Asian female, mandarin speaking, single, unemployed, domiciled at ACMH Markus Gardens, with Past Psychiatric History of Schizoaffective disorder – bipolar type, brought in by EMS after patient reportedly made suicidal statements to the group home staff. Patient states that she gave all her money to family, and does not have money to buy food, therefore, she cannot support herself. Patient also complains that she has had auditory hallucinations recently, reporting that the voices told her that she was “protected by the police”. The last time she heard the voice was last night. Patient states she receives Cogentin and Depakote from Dr. Zhu, her ACMH Physicians. She has compliant with these medications. But she reports the medications did not help her.

Upon psychiatric evaluation in Comprehensive Psychiatric Emergency Program (CPEP) today, patient appears well groomed and well nourished, cooperative with the interview and provides detailed responses to questions. Patient is calm. Her thought processes and content are coherent, and speech is fluent. Patient denies any suicidal or homicidal ideation, intent, or plan, saying “I would never hurt myself or other people.” Chart review reveals many suicides thought in the past 6 months; however, patient appears to be minimizing the situation.

Collateral information was obtained from ACMH assistant director, who report that a close friend of the patient committed suicide last year with unknown reason. However, the patient was crying and appeared sad today, and told the social worker that the reason for her friend killed himself was because he could not support himself, which is the same as her current situation. And during the communication with the patient, she also said “I don’t want to live anymore.” Due to that statement, the social worker was concerned about the patient and called the police. Medications and dosages that patient takes at Group Home was confirmed by staff, and patient was compliant with her meds.

Past Medical History:

Denies

Past Psychiatric History:

Mood disorder

Schizoaffective disorder

Allergies:

No reported drug, food, or environmental allergies

Medications:

Benztropine (Cogentin) 0.5mg, one tablet by mouth twice daily

Divalproex (Depakote) 500 mg, one tablet by mouth twice daily

Haloperidol decanoate (Haldol decanoate) 100 mg/mL IM every 28 days

Family History:

Denies family history of any psychiatric disorders.

Social and Occupational History:

Patient is a Chinese female, who has a high school degree. Patient states she worked as a health care aide several years ago, but she cannot back to work due to her psychiatric disorder. Patient states she loves her parents, but she gets very upset at them when they ask money from her. When asked about her social support, patient states “I have some friends, but they do not want to talk with me, because they know I have psychiatric issues”. Patient states she has many admissions to a psychiatric ER. Patient states she is hungry right now and has not eaten enough food recently, due to lack of money.

Review of Systems -Psychiatric:

Positive auditory hallucination and feeling of sadness. Denies feelings of depression, hopelessness, anhedonia, anxiety, difficulty sleeping, or decreased appetite. Denies suicidal ideations, homicidal ideations, or visual hallucinations.

Physical Exam:

General Survey: 28 year old Chinese female, alert and oriented to person, place and time, well dress and groomed. Appears her stated age, thin and fit. Calm and cooperative, constricted affect.

Vital Signs: BP: 99/61 Pulse:70 Respirations: 18 Temperature: 97.5 °F, oral O2 saturation: 97% Height 6 feet 4 inches Weight: 152 pounds

Mental Status Exam:

General

1. Appearance: CJ is an average height and build, and fit Chinese female. CJ is dressed in a pink hoodie and Jeans, found sitting up in a chair. CJ appears well-kempt and appears her stated age of 28.
2. Behavior and Psychomotor Activity: CJ did not have excessive non-purposeful motor activity, or slowed motor activity and response times. appears calm and cooperative and responds in normal tone and moderate volume.
3. Attitude toward Examiner: CJ is polite toward examiner. Patient appears calm and cooperative. She established adequate rapport for the purposes of completing the examination.

Sensorium and Cognition

1. Alertness and Consciousness: CJ was alert and her level of consciousness did not fluctuate during the interview.
2. Orientation: CJ was oriented to person, place and time.
3. Concentration and Attention: CJ appears concentrate on the verbal during the interview.
4. Capacity to Read and Write: CJ has the ability to read and write Chinese.
5. Visuospatial Ability: CJ has normal visual perception.
6. Abstract Thinking: CJ has adequate ability to interpret metaphors and understand similarities/differences.
7. Memory: CJ’s remote, recent and immediate memory were satisfactory. Pt was able to describe her past, as well as give information about her recent activities.
8. Fund of Information and Knowledge: CJ has adequate information and knowledge base yet does not understand why she needs to be observed in CPEP.

Mood and Affect

1. Mood: CJ’s mood was even tempered.
2. Affect: CJ’s affect exhibited a normal range of expression.
3. Appropriateness: Affect and mood are consistent with thought content, but patient appears to be minimizing any her history of suicidal ideation.

Motor

1. Speech: CJ has normal rate and tone of speech, with clear articulation.
2. Eye Contact: CJ has adequate eye contact while speaking and listening.
3. Body Movements: CJ’s body movements were purposeful and organized, without tremors, tics or abnormal movements. Her gait and station were normal. She was able to remain seated throughout the exam.

Reasoning and Control:

1. Impulse Control: CJ had satisfactory ability to control her impulses. She did not have suicidal thoughts or impulses.
2. Judgment: CJ exhibits adequate judgement. She could process information and make normal decisions based on it. The content of CJ’s thoughts did not focus on a particular theme.
3. Insight: CJ exhibits poor insight. When asked why she came to the hospital, patient states, “I’m hungry, I do not have money to buy food. The only thing I need is food.”

Assessment: Patient is a 28 year old Asian female, unemployed, domiciled at ACMH Markus Gardens, with Past Psychiatric History of Schizoaffective disorder – bipolar type, brought in by EMS after patient reportedly made suicidal statements to the group home staff. Differential diagnosis includes Schizoaffective disorder, schizophrenia, major depression disorder with psychotic feature, metabolic disturbance.

Schizoaffective disorder: Schizoaffective disorder shares symptoms with both mood and other psychotic disorders. For CJ, she has more prominent depressive symptoms, less severe negative symptoms and hallucinations, and better overall functioning. Therefore, her situation is highly suspect with schizoaffective disorder.

Schizophrenia: Schizophrenia is characterized by psychotic symptoms (hallucinations, delusions, and disorganized thoughts and behaviors.) for a significant portion of a month. Diagnosis of schizophrenia requires that symptoms are associated with a decline in functioning or failure to achieve the expected level of function. Physical examination showed that the patient was alert and oriented. In addition, patient has experienced depression episode. Therefore, schizophrenia is less likely.

Major depression disorder with psychotic feature: When delusions or hallucinations occur exclusively during periods of mood disturbance, the diagnosis of mood disorder with psychotic features may be used. Usually, psychotic symptoms last longer in schizoaffective disorder than they do in mood disorders. In mood disorder with psychosis, the mood disorder usually precedes the psychosis, and the psychosis normally begins as the mood symptoms increase and psychosis remits when mood symptoms decrease. For CJ, her psychosis symptom was more dominate and precedes the mood disorder. Therefore, the major depression disorder with psychotic feature is less likely.

Metabolic disturbance: such as B12 deficiency or hypothyroidism, may also cause the symptom of hallucination. So basic labs (CBC, BMP, thyroid panel) should be ordered to rule out metabolic disturbance.

Diagnosis:

Schizoaffective disorder, bipolar type F25.0

Plan:

1. Patient will be admitted to CPEP for behavioral observation due to prior history of schizoaffective disorder and continued suicidal thought.
2. Medications:
   1. Increase the dosage of Benztropine (cogentin) from 0.5 mg to 1 mg
   2. Switch Divalproex (depakote) from 500 mg to ER tablet 1,250 mg
   3. Add Quetiapine (seroquel) tablet 100 mg PO nightly for schizophrenia symptom, bipolar symptom, and depression.
   4. Add Trazodone (desyrel) tablet 50 mg PO nightly for depression
3. Labs: CBC, CMP, THC, UA, urine toxicology, COVID-19 PCR test
4. Counsel patient on importance of medication compliance and warm about abrupt cessation of medication.
5. Reassess patient for suicidality and complete safety plan
6. Re-evaluate in the morning.