CHIEF COMPLAINT
Inpatient psychiatric evaluation for depression with suicidal ideation
LEGAL STATUS
Involuntary
HISTORY OF PRESENT ILLNESS
Per Crisis note:
Pt is a 17 yo M with past psychiatric history of Bipolar disorder and ODD in the foster care system who presented to Crisis under BA. Per BA, patient has been feeling depressed and voiced suicidal ideation in the presence of law enforcement. On interview patient is calm but appears dysphoric and tired, endorsing multiple stressors. Pt voiced concern about 1:1 sitter in group home stating that a few days ago he realized that she was "grooming him." Patient reports that the 1:1 sitter will no longer be at group home and that he feels safe living there. About 1.5 months ago pt presented to Larkin Hospital for similar presentation. At the time, his medications were changed to Quetiapine, Oxcarbazepine, and Bupropion. Pt endorses medication compliance however pt mother (Christine Long 786-333-1039) could not be reached. Pt denies suicidal/homicidal thoughts/intent/plan. Patient denies AVH and no delusions were elicited. No manic sx were elicited.
The patient was seen this morning, discussed with the ancillary staff, and the chart was reviewed. Upon interview today, pt continued to endorse stressor regarding the 1:1 attendant that was "grooming him" stating she was making purchases for him, sending him inappropriate sexual text messages despite the pt blocking her from his social media accounts. Pt endorses that these events have made him feel depressed and anxious. He is uncomfortable with his social situation, considering DCF told him that his mother had put him up for foster care, was unhappy with foster-parents, currently living in foster group home, and incident with 1:1 attendant in the past, feeling hopeless. Pt endorses passive SI, with no plan, denies HI, denies AVH. Pt is currently in a group home in Citrus, with case manager Jazmin (786-769-4961), who also endorses pt has been regularly taking Quetiapine 100mg PO Bedtime, Oxcarbazepine 150mg PO BID, Bupropion 150mg daily. Pts mother (786 333-1039) was called who states she has not been in much contact with the pt. Patient endorses fair sleep/appetite, denies any manic symptoms, denies perceptual disturbances, denies paranoia, and is not grossly delusional.
TARGET SYMPTOMS
Quality: depression with suicidal ideation
Duration: days
Severity: severe, interfering with ability to care for self / interfering with safety of self
Context: precipitating stressor for admission
Modifying factors: medication optimization, therapeutic milieu
Associated S/S: see HPI and MSE
REVIEW OF SYSTEMS
General: does not endorse fevers or weight change
HEENT: does not endorse sore throat or congestion
Cardiovascular: does not endorse chest pain or palpitations
Respiratory: does not endorse cough or wheezing
Gastrointestinal: does not endorse nausea, vomiting, or changes in bowel habits
Genitourinary: does not endorse dysuria or change in bladder habits
Neurological: does not endorse dizziness or numbness
MSK: does not endorse muscle or joint pain
(from chart review and updated as appropriate)
PAST PSYCHIATRIC HISTORY:
Inpatient: multiple hospitalizations; most recent CAAP hospitalization in 5/8/22
Outpatient: yes, but does not follow up
Pt has h/o aggression, no prior SA or SIB
Has been kicked out of multiple residential programs (last in May 2021 out of state but he was kicked out for aggressive behavior)
previously tried on haldol, risperdal, prolixin, thorazine
Abuse: currently living in foster group home; has a case manager.
Substance abuse: denies
SUBSTANCE USE HISTORY:
Tobacco: Regularly smokes vape pen
Alcohol: denies
Cannabis: 1-2x month
Cocaine: denies
Opioids: denies
Benzodiazepines: denies
Amphetamines: denies
Hallucinogens: denies
Detox/Rehab: denies
PAST MEDICAL HISTORY:
none
ALLERGIES:
No Known Medication Allergies; NKA
FAMILY HISTORY:
Bipolar disorder: Grandmother (M).
Depression: Grandmother (M).
SOCIAL HISTORY:
History of emotional, sexual, and/or physical abuse: endorses sexual abuse with prior 1:1 attendant
Living Situation: group home (foster care)
Legal History: denies
Support system: poor
PSYCHIATRIC SPECIALTY EXAMINATION
Vital Signs
Temperature 36.6 (14:04)
Systolic Blood Pressure 124 (14:04)
Diastolic Blood Pressure 78 (14:04)
Pulse 78 (14:04)
SpO2 100 (14:04)
Respiratory Rate 18 (14:04)
Mental Status Exam
Appearance: adequate grooming and hygiene
Behavior: calm and cooperative with interview
Eye Contact: good
Motor Activity: no PMA/PMR/AIMs noted
Speech: normal rate and rhythm, appropriate volume, spontaneous, comprehensible
Mood: "im upset"
Affect: depressed, restricted, congruent.
Thought Process: organized, goal directed
Thought Content:
- Delusions: No delusions elicited
- Perceptual Disturbances: denies perceptual disturbances, not overtly RTIS
Suicidal Ideation/Thought/Intent/Plan: denies
Homicidal Ideation/Thought/Intent/Plan: denies
Cognition
- Attention/Concentration: fair/fair to interview
- Orientation: awake, alert, oriented to person, location, date, situation
Insight/Judgment: poor/poor
Laboratory Test Results
Laboratory or Other Results This Visit (last charted value for your 07/04/2022 visit)
Infectious Disease Testing
07/04/2022 4:05 PM
SARS CoV 2 RNA, RT PCR: Negative
Assessment
Diagnosis or problem list prompting current evaluation:
Diagnoses
Bipolar disorder, unspecified (F31.9)
Oppositional defiant disorder (F91.3)
End of Diagnoses List
Plan
1. Patient has acute psychiatric symptoms and is in need of treatment and stabilization. Psychiatric symptoms intolerable to patient and/or society and at risk of re-hospitalization. Patient continues to require 24 hour observation, nursing care, and inpatient treatment and cannot be treated in a less restrictive environment.
2. Medications:
Medications (6) Active
Scheduled: (3)
buPROPion 150 mg, ORAL, DAILY
OXcarbazepine 150 mg Tab 150 mg 1 tab, ORAL, BID
QUEtiapine IR 100 mg Tab 100 mg 1 tab, ORAL, BEDTIME
Continuous: (0)
PRN: (3)
magnesium hydrox (MOM) Liquid 30 mL 30 mL, ORAL, Q12H
mg hydrox/al hydrox/simeth Susp 30 mL 30 mL, ORAL, Q6H
nicotine 2 mg Loz 2 mg 1 lozenge, TRANSMUCOSAL, Q2H
3. Tobacco Cessation: n/a
4. Labs/Imaging: none
5. Consults: none
6. Court Date: none / TBD
7. Social work evaluation for disposition and follow-up.
8. Patient was educated about reasons for prescribing the above medications, expected benefits and likelihood of clinical improvement, as well as potential side effects and relevant risks; treatment alternatives and side effects of the alternatives expected course without treatment and results of not receiving care. Patient was educated on how to take the medications.
Case seen and discussed with Dr. Bez
Addendum By Yasin Bez, MD
Psychiatry Attending Attestation:
I saw and evaluated the patient and discussed the management plan with the resident/fellow. I reviewed the note and agree with the documented findings and plan of care.
Visitor restrictions due to Covid-19 are in place.
Patient with no notable/reported exposures, no known sick contacts, no reported recent travel and is not stated to be an at-risk population. Patient has not displayed any symptoms of cough, GI distress, Rhinorrhea, Anosmia, or fever while on the unit. COVID testing was negative.