Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation/PRAC 6635: Psychopathology and Diagnostic Reasoning Practicum
imazdm25
CHIEFCOMPLAINT.docx.
CHIEF COMPLAINT "My son died last Tuesday"
HISTORY OF PRESENT ILLNESS
Patient seen today, chart reviewed, patient was admitted as a transfer from Jackson North where she presented with family for altered mental status, psychosis, hallucinations and questionable suicidality. She was PC'd at Jackson North a doctor for "patient is psychotic with delusions and hallucinations, has disorganized thoughts", signed 9/24/21. Sh ewas medically cleared on 9/29. She was followed by consultation liaison service. She has no previous admissions to JBHH, at least with this Medical Record Number. Collateral needed. She is creole speaking, Creole speaking RN at bedside. She states that she is here because her family brought her and that her son passed away last Tuesday. However, again, collateral needed from family. She is disorganized in her thought process, with psychosis and possibly RTIS.
PAST PSYCHIATRIC HISTORY
Admissions: None at JBHH
Outpatient TX: None
Current meds: None
Prior meds: Unknown
Prior suicide attempts: Denies
PSYCHOLOGICAL TRAUMA ABUSE AND NEGLECT HISTORY
1. Trauma History: Denies 2. Physical Abuse: Denies 3. Domestic violence: Denies 4. Emotional Abuse: Denies 5. Neglectful relationship: Denies
6. Financially exploited: Denies 7. Exploitation: Denies
SUBSTANCE USE HISTORY
Denies
Tobacco Prevention Metrics:
Have you smoked tobacco in the last 30 days: No
Was nicotine replacement therapy provided: N/A
FDA smoking cessation medication: None Past Marchman Act: No Past Rehabilitation Unit admissions: No Past Detoxification Unit admissions: No Past Outpatient Substance Use: No AA/NA participation: No Compliance: No
PAST MEDICAL HISTORY
Medical problems: Recent AMS, HTN, COVID Positive
Surgeries: Denies
Seizures: Denies
Medications (active):
Medication List
Active Medications
Ordered
acetaminophen: 650 mg, 2 tab, ORAL, Q6H, PRN: Pain - Mild.
Prescribed
ascorbic acid: 500 mg, 1 tab, ORAL, BID, 60 tab, 0 Refill(s).
cholecalciferol: 10 mcg, 1 tab, ORAL, BID, for 30 day(s), 60 tab, 0
Refill(s).
zinc sulfate: 220 mg, 1 cap, ORAL, DAILY, 30 cap, 0 Refill(s).
Medications Inactivated in the Last 72 Hours
acetaminophen: 650 mg, 2 tab, ORAL, Q4H, PRN: Pain - Mild.
acetaminophen: 650 mg, 2 tab, ORAL, Q4H, PRN: Fever.
ascorbic acid: 500 mg, 1 tab, ORAL, BID.
cefTRIAXone: 1 g, 10 mL, IV, Q24H.
cholecalciferol: 400 Int_Unit, 1 tab, ORAL, BID.
docusate: 100 mg, 1 cap, ORAL, DAILY, PRN: Constipation.
famotidine: 20 mg, 2 mL, IV, BID.
hydrALAZINE: 10 mg, 0.5 mL, IV PUSH, Q6H, PRN: BP Abnormal.
LORazepam: OVERRIDE, ONCE.
LORazepam: OVERRIDE, ONCE.
LORazepam: 2 mg, 1 mL, IV PUSH, ONCE.
morphine: 2 mg, 1 mL, IV, Q4H, PRN: Pain - Severe.
nitroglycerin: 0.4 mg, 1 tab, SUBLINGUAL, Q5MIN, PRN: Chest Pain.
ondansetron: 4 mg, 2 mL, IV, TID, PRN: Nausea/Vomiting.
zinc sulfate: 220 mg, 1 cap, ORAL, DAILY.
REVIEW OF SYSTEM: General: Denies Fever, chills, dizziness, weakness. Eye: Denies redness, discharge, visual loss, blurred vision, vision change. ENT: Denies Sore throat, Nosebleed, Rhinorrhea, Throat swelling, hearing loss. Cardiovascular: Denies Chest Pain, Rapid heartbeat, lower extremities swelling, palpitations, orthopnea. Respiratory: Denies SOB, productive cough, hemoptysis. Gastrointestinal: Denies nausea, vomiting, diarrhea, constipation, bloating, melena. Genitourinary: Denies dysuria, frequency, flank pain, hematuria. Muscular: Denies myalgia, neck/back pain, arthralgia, redness. Skin: Denies rash, swelling, lacerations, abrasions. Neurologic: Denies headaches, numbness, change LOC, weakness, paresthesia, change in speech. Hematologic: No bruising, no petechiae, no bleeding.
Pain Assessment: 1. Pain present: No actual or suspected pain Numeric score, if present (1-10): 0
VITALS
Vital Signs
|
Height Description: Estimated |
|
Height: 180.3 cm |
|
Weight Description: Estimated |
|
Weight: 61.05 kg |
|
Body Mass Index: 18.78 |
|
Weight Dosing: 61.05 kg |
|
Height Standard: 71 inch |
|
Height Calculated: 180.34 cm |
|
Body Mass Index Estimated: 18.78 |
|
Height/Length Dosing: 180.3 cm |
|
Body Mass Index Dosing: 18.78 |
|
Body Surface Area Dosing: 1.097 |
|
Temperature Oral: 36.5 DegC Low |
|
Peripheral Pulse Rate: 73 bpm |
|
Respiratory Rate: 18 br/min |
|
Systolic Blood Pressure: 105 mmHg |
|
Diastolic Blood Pressure: 64 mmHg |
|
Cuff Location: Right arm |
|
Mean Arterial Pressure, Cuff: 78 mmHg |
|
Blood Pressure Position: Sitting |
PSYCHOSOCIAL HISTORY
Social & Psychosocial Habits
Tobacco
09/29/2021 Smoking tobacco use: Never tobacco user
Smokeless tobacco use: Never
Substance Abuse
09/29/2021 Use: Denies substance abuse
Alcohol
09/29/2021 Use: Denies alcohol use
Abuse/Neglect/Domestic Violence
09/29/2021 Injuries/Abuse/Neglect in household: No
Hit, slapped, kicked, punched, choked, or physically hurt yo No
Threatened you or made you feel afraid: No
Touched you or forced you to have sex in a way you did not w No
Refused you food, medicines, or medical aids: No
Feels safe at home: Yes
Safe place to go: Yes
Electronic Cigarette/Vaping
09/29/2021 Use Never
PERTINENT LABS/IMAGING:
Last Month
|
Basic Metabolic Panel: |
Hematology: |
|
Sodium: 141 mmol/L (09/24/21) |
Hemoglobin: 12.8 g/dL (09/25/21) |
|
Potassium: 3.9 mmol/L (09/24/21) |
: () |
|
: () |
WBC Count: 5.7 x10(3)/mcL (09/25/21) |
|
Magnesium Level: 1.1 mg/dL (09/24/21) |
Platelet Count: 212 x10(3)/mcL (09/25/21) |
|
Blood Urea Nitrogen: 16 mg/dL (09/24/21) |
INR POC: ------ |
|
Creatinine POC: 0.90 mg/dL (09/24/21) |
|
|
: () |
|
|
Urinalysis: |
|
|
: () |
Urine Blood: 0.2 mg/dL (09/24/21) |
|
Nitrites: Neg (09/24/21) |
Protein: Neg (09/24/21) |
|
Ketones: Neg mg/dL (09/24/21) |
Urine Color Urine Dipstick: ------ |
|
Leukocyte Esterase: 75 (09/24/21) |
: () |
|
Bilirubin: Neg mg/dL (09/24/21) |
Urine pH: 5.0 (09/24/21) |
|
Urobilinogen: Negative mg/dL (09/24/21) |
Specific Gravity: 1.015 (09/24/21) |
Additional - Last Month
|
Absolute Basophil: 0.05 x10(3)/mcL (09/25/21) |
Absolute Eosinophil: 0.50 x10(3)/mcL (09/25/21) |
Absolute Immature Granulocyte: 0.02 x10(3)/mcL (09/25/21) |
|
Absolute Lymphocyte: 2.5 x10(3)/mcL (09/25/21) |
Absolute Monocyte: 0.8 x10(3)/mcL (09/25/21) |
Absolute Neutrophil: 1.9 x10(3)/mcL (09/25/21) |
|
Acetaminophen Level: <10.0 mg/L (09/24/21) |
Albumin Level: 4.7 g/dL (09/24/21) |
Alkaline Phosphatase: 71 unit/L (09/24/21) |
|
ALT (SGPT): 17 unit/L (09/24/21) |
Amphetamine Class: Negative (09/24/21) |
Anion Gap: 13 (09/24/21) |
|
AST (SGOT): 28 unit/L (09/24/21) |
Bacteria: Trace (09/24/21) |
Basophil (%): 0.9 % (09/25/21) |
|
Benzodiazepine Class: Negative (09/24/21) |
C-Reactive Protein: 0.6 mg/dL (09/24/21) |
Calcium Level: 10.0 mg/dL (09/24/21) |
|
Cannabinoid: Negative (09/24/21) |
Chloride: 102 mmol/L (09/24/21) |
Clarity: Clear (09/24/21) |
|
Cocaine & Metabolites: Negative (09/24/21) |
Color: Yellow (09/24/21) |
D DIMER Quantitation: 1.92 mcg/mL FEU (09/25/21) |
|
eGFR (African-American): 87 (09/24/21) |
eGFR (Non African-American): 75 (09/24/21) |
Eosinophil (%): 8.7 % (09/25/21) |
|
Ethanol Level: <10 mg/dL (09/24/21) |
Ferritin: 130 ng/mL (09/25/21) |
Flu A: n/a (09/28/21) |
|
Flu B: n/a (09/28/21) |
Glucose: 103 mg/dL (09/24/21) |
Glucose: Negative mg/dL (09/24/21) |
|
HCV ED Protocol: Non Reactive (09/25/21) |
Hematocrit: 38.5 % (09/25/21) |
HIV AG/AB: Non Reactive (09/25/21) |
|
Immature Granulocyte (%): 0.3 % (09/25/21) |
LDH: 580 unit/L (09/24/21) |
Lymphocyte (%): 43.5 % (09/25/21) |
|
MCH: 28.6 pg (09/25/21) |
MCHC: 33.2 g/dL (09/25/21) |
MCV: 86.1 fL (09/25/21) |
|
Monocyte (%): 13.4 % (09/25/21) |
MPV: 11.0 fL (09/25/21) |
Neutrophil (%): 33.2 % (09/25/21) |
|
NRBC%: 0.0 /100WBC (09/25/21) |
NRBC(Abs): 0.00 x10(3)/mcL (09/25/21) |
Opiate Class: Negative (09/24/21) |
|
Osmolality Calculated: 282 mOsm/kg (09/24/21) |
Other Respiratory Virus/Bacteria: unknown (09/28/21) |
Procalcitonin: .061 ng/mL (09/24/21) |
|
RBC Count: 4.47 x10(6)/mcL (09/25/21) |
RDW-CV: 13.7 % (09/25/21) |
RSV: n/a (09/28/21) |
|
Salicylate Level: <1.0 mg/dL (09/24/21) |
SARS CoV 2 RNA, RT PCR: Positive (09/28/21) |
Slide Review: Not Indicated (09/25/21) |
|
Squamous Epithelial Cell: 2 (09/24/21) |
Total Bilirubin: 1.4 mg/dL (09/24/21) |
Total CO2 Content: 26 mmol/L (09/24/21) |
|
Total Protein: 8.7 g/dL (09/24/21) |
U Barbiturate Class: Negative (09/24/21) |
U Methadone: Negative (09/24/21) |
|
U Phencyclidine: Negative (09/24/21) |
Urine Microscopic: Indicated (09/24/21) |
Urine RBC's: 5 /HPF (09/24/21) |
|
Urine WBC's: 11 /HPF (09/24/21) |
|
|
Vital Signs
|
Height Description: Estimated |
|
Height: 180.3 cm |
|
Weight Description: Estimated |
|
Weight: 61.05 kg |
|
Body Mass Index: 18.78 |
|
Weight Dosing: 61.05 kg |
|
Height Standard: 71 inch |
|
Height Calculated: 180.34 cm |
|
Body Mass Index Estimated: 18.78 |
|
Height/Length Dosing: 180.3 cm |
|
Body Mass Index Dosing: 18.78 |
|
Body Surface Area Dosing: 1.097 |
|
Temperature Oral: 36.5 DegC Low |
|
Peripheral Pulse Rate: 73 bpm |
|
Respiratory Rate: 18 br/min |
|
Systolic Blood Pressure: 105 mmHg |
|
Diastolic Blood Pressure: 64 mmHg |
|
Cuff Location: Right arm |
|
Mean Arterial Pressure, Cuff: 78 mmHg |
|
Blood Pressure Position: Sitting |
MENTAL STATUS EXAM:
General Appearance: Seen in room, lying in bed, alone
Behavior: Superficially Cooperative, Hospital Attire, Unkempt
Attitude: Engaged in treatment with Prompting
Eye contact: Minimal Eye Contact
Level of alertness: AAOX3
Motor function: Restless, Easily Irritable
Orientation: AAOX3
Speech: Clear and Coherent
Mood and Affect:
Mood: Dysphoric
Affect: Constricted, Blunted
Thought Process: Disorganized
Thought Content: Delusions: Paranoid, Guarded
Content of thought: Preoccupied with Psychosocial Stressors, Discharge
Perceptual disturbances: May be RTIS
Insight and Judgment: Limited
Attention and Concentration: Limited
Recent and Remote Memory: Appropriate
Language: English
Fund of Knowledge: Consistent with Educational Level
Risk: Adamantly Denies S/H TIP
Patient strengths:
Patient is motivated for treatment, is compliant with medications,
has good insight, judgment, and effective coping skills,
is alert and oriented to spheres , has adequate appetite and intake to meet daily metabolic needs,
is mobile and has a steady gait, can accomplish ADL's without assistance,
intellectually capable, able to verbalize problems,
understands treatment interventions, able to identify outside stressors
cooperative with treatment
DIAGNOSTIC IMPRESSION: (based on DSM-5 diagnostic criteria)
Major depressive disorder, recurrent, severe with psychotic symptoms (F33.3)
INITIAL TREATMENT PLAN
Admit for Stabilization, Legal Status is Voluntary
Initial Psychiatric Assessment and Follow-Up
Multidisciplinary Team Assessment and Follow-Up
Medical Assessment and Follow-Up As Needed
Social Work Assessment and Follow-Up
Pharmacy Assessment and Follow-Up
Nursing assessment and Follow-Up
Recreational Therapy
Occupational Therapy
Individual Therapy
Music Therapy
