Week 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation/PRAC 6635: Psychopathology and Diagnostic Reasoning Practicum
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ChiefComplaint.docxChief Complaint: " The voices are telling me bad stiff" HPI: This is a 26 year old female (24 weeks pregnancy) with prior behavioral health history of Schizophrenia that was brought in to the JMHBH ED by transfer from another institution (PC)from Palmetto Hospital due to grossly psychotic behaviors and pulling out her IVF Upon arrival to the crisis unit, this patient initial presentation consisted of a tearful client that was RTIS with auditory hallucinations. Patient was send to the medical ED for OB/Medical clearance and she had performed there the following test: X-Ray ankle: only found with soft tissue swelling, Ct Scan Brain: WNL, OB-US: viable fetus with 23 weeks and 6 days old.
Patient was seen and evaluated in the room and found with the her bedroom full of water after patient brought her mattress to the shower area and attempted to take a shower on top of her mattress. Unit nursing staff assisted patient getting dressed and removed the mattress from the shower area. Patient manifested having derogatory type auditory hallucinations but she could not expressed the set of circumstances leading to present admission. Patient was noticed to have derogatory type auditory hallucinations, disorganized speech (frequent derailment or incoherence), grossly disorganized behavior, poverty of speech and thoughts, diminished emotional expression , apathy, anhedonia, reduced social drive, lack of social interest, RTIS, internally preoccupied and thought blocking.
The patient was unable to engage in a meaningful interview due to level of thought disorganization. The patient represents an acutely elevated risk of harm to self and others and requires inpatient psychiatric hospitalization for stabilization and management.
Based on current presentation and symptoms reported by patient and observed behaviors there is evidence of patient posing a danger to self or others if untreated therefore patient needs inpatient admission for behavioral observation and suicide risk assessment
There is evidence of symptoms and behavior reflecting significant risk /potential to harm self /others if not treated.
Reason for Admission: (From Crisis Unit by Siegmeister, Jerome on 10.11.2021 at 1312 )
History of Present Illness
"This is a 26 year old female with a PPHx of schizophrenia, bipolar disorder, depression, anxiety, and PMHx of hypothyroidism, 25 weeks pregnant presenting under PC from Palmetto hospital after attempting to pull her IV lines and acting grossly psychotic. Interview conducted in Spanish. Patient originally was at home when she decided to call the police because she felt "flustered", family took the patient to Palmetto hospital before police arrived. Unable to meaningfully participate in the interview, however denies SI/HI, denies AVH. States she has not taken her risperidone for the past month as she believes the medication will harm her fetus. Patient later became more psychotic throughout interview, growing tearful and RTIS, cursing to passerby and appearing to be experiencing AH. Denies cocaine, nicotine, alcohol or cannabis use.
Patient remained manic with gross RTIS after given PRN risperidone, and fell in triage, necessitating medical evaluation. She has been medically cleared, and now returns to triage for planned admission.
Target Symptoms: Quality – psychosis Duration – days to weeks Timing – increasing / acute Severity - moderate Context – adjustment in medications, noncompliance with medications Modifying factors: Aggravating: medication noncompliance Alleviating: hospitalization, compliance with meds, sleep Interfering with daily functioning: Yes Interfering with safety of self/others: Yes Causing self-neglect: No Associated signs and symptoms: · Suicidal ideation – No · Command type hallucination – No · Delusions – No · Depression/helplessness/hopelessness – No · Sleep disturbances – No Past Psychiatric History: Past inpatient hospitalizations: One previous JMH admission dating back 2014 (D/C on: risperdal 1mg Po BID). patient claims multiple previous hospitalizations at Hialeah Hospital, Palmetto Hospital and Citrus Health. Past state hospitalizations: Denied Past outpatient: no formal f/u for the past several months. Compliance: non-compliance with risperdal ECT: No Individual/group therapy: No Past suicide attempts: denied Past violence: denied Past Substance Abuse History: Type of Substance:
* Patient will not voluntarily provide this information at this time.
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: TBI / LOC / Black outs: None Seizures: No
Hxt. Hypothyroidism (On synthroid 100mcg PO QD) Allergies: NKA Past Surgical History: None Abuse and Neglect: 1. Trauma History: None 2. Physical Abuse: None 3. Domestic violence: None 4. Emotional Abuse: None 5. Neglectful relationship: None 6. Financially exploited: None 7. Exploitation: None Homicide Risk assessment: 1. Thoughts of harming someone: None 2. Having you ever been so upset or angry that you thought of killing or harming someone: None 3. Have you ever tried to kill or harm anyone: None A. Were you arrest: N/A Nutritional Assessment: 1. Has there been a weight loss or gain of 10 pounds or more in the past three months: None 2. Changes in appetite: None 3. Dental problems in the last 3 to 6 months: None 4. Eating habits: None Pain Assessment: 1. Pain present: No actual or suspected pain Numeric score, if present (1-10): 0 Location if present: Quality if present: Family History: Family history: negative Mental illness: denies Suicide attempts: denies Substance abuse: denies Medical problems: denies Dementia: denies Social/Legal History: Legal: Denied Employment: Unemployed living situation: lives with family member support system: limited 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. Mental Status Exam: Appearance: suspicious / limited hygiene and groomed / restless Behavior: partially uncooperative Alert and oriented : person, place Eye contact: poor / avoidant Speech: poverty Mood: expansive / angry Affect: blunted / labile Thought process: disorganized / tangential / thought blocking Thought content: paranoid Perceptual disturbances: + auditory hall non-command type / + RTIS Suicidal ideation/intention/plan: no Homicidal ideation/intention or plan: no Insight: limited Judgement: limited Attention and Concentration: poor Columbia Suicide Severity Rating Scale Since Last Visit Wish to be Dead: Since Last Visit Wish to be Dead: No Since Last Visit Suicidal Thoughts: No Since Last Visit Idea w-Method No Intent: No Since Last Visit Idea w-Intent No Plan: No Since Last Visit Suicide Intent w-Plan: No Since Last Visit Suicide Behavior: No Homicidal T/I/P: Medications:
Medication List
Active Medications
Ordered
acetaminophen: 650 mg, 2 tab, ORAL, Q6H, PRN: Headache.
diphenhydrAMINE: 50 mg, 1 mL, IM, Q6H, PRN: Agitation.
haloperidol: 5 mg, 1 tab, ORAL, Q6H, PRN: Agitation.
haloperidol: 5 mg, 1 mL, IM, Q6H, PRN: Agitation.
influenza virus vaccine, inactivated: 0.5 mL, IM, BEFORE DISCHARGE.
levothyroxine: 100 mcg, 1 tab, ORAL, DAILY.
magnesium hydroxide: 30 mL, ORAL, Q12H, PRN: Constipation.
multivitamin, prenatal: 1 tab, ORAL, DAILY.
nicotine: 2 mg, 1 lozenge, TRANSMUCOSAL, Q2H, PRN: See Comment.
risperiDONE: 1 mg, 1 tab, ORAL, BEDTIME.
Prescribed
ethinyl estradiol-levonorgestrel: 1 tab, ORAL, DAILY, 30 tab, 11
Refill(s).
omeprazole: 20 mg, 1 cap, ORAL, DAILY, 30 cap.
Documented
acetaminophen: 500 mg, ORAL, takes as needed..
levothyroxine: 100 mcg, ORAL, DAILY.
naproxen: mg, tab, ORAL, BID.
risperiDONE: 1 mg, 1 tab, ORAL, BEDTIME, 60 tab.
sertraline: 50 mg, 1 tab, ORAL, DAILY, 30 tab.
Medications Inactivated in the Last 72 Hours
acetaminophen: 1,000 mg, ORAL, ONCE, PRN: Pain - Mild.
acetaminophen: OVERRIDE, ONCE.
acetaminophen: OVERRIDE, ONCE.
diphenhydrAMINE: 25 mg, 0.5 mL, IM, ONCE.
haloperidol: 5 mg, IM, Q6H, PRN: Agitation.
haloperidol: OVERRIDE, ONCE.
haloperidol: OVERRIDE, ONCE.
hydrOXYzine: OVERRIDE, ONCE.
hydrOXYzine: 50 mg, ORAL, ONCE.
levothyroxine: 100 mcg, 1 tab, ORAL, DAILY.
levothyroxine: OVERRIDE, ONCE.
magnesium hydroxide: 30 mL, ORAL, Q12H, PRN: Constipation.
multivitamin, prenatal: OVERRIDE, ONCE.
promethazine: 25 mg, IM, ONCE, PRN: Nausea/Vomiting.
promethazine: OVERRIDE, ONCE.
risperiDONE: OVERRIDE, ONCE.
risperiDONE: 4 mg, 1 tab, ORAL, ONCE.
risperiDONE: 2 mg, 1 tab, ORAL, BEDTIME.
risperiDONE: 2 mg, 1 tab, ORAL, ONCE.
risperiDONE: 2 mg, ORAL, ONCE.
risperiDONE: 2 mg, ORAL, BEDTIME.
Immunizations:
Immunizations
No Immunizations Documented This Visit
Vital Signs/Measurements/Pain Intensity:
Temperature 36.6 (03:10)
Systolic Blood Pressure 113 (03:10)
Diastolic Blood Pressure 54 (03:10)
Pulse No result
SpO2 No result
Respiratory Rate No result
Lab Results:
Last Month
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Lipid Profile: |
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Triglyceride: 175 mg/dL (10/11/21) |
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Cholesterol, Total: ------ |
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HDL POC: ------ |
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LDL POC: ------ |
Additional - Last Month
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Calculated LDL: 63 mg/dL (10/11/21) |
Cholesterol: 155 mg/dL (10/11/21) |
Glycohemoglobin: 4.9 % A1C (10/11/21) |
|
HDL: 57 mg/dL (10/11/21) |
SARS CoV 2 RNA, RT PCR: Negative (10/10/21) |
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Diagnosis:
Diagnoses
1. Acute Exacerbation of Chronic Schizophrenia (F20.9)
2.Encounter for supervision of normal pregnancy, unspecified, unspecified trimester (Z34.90)
End of Diagnoses List
Assessment/Plan: Disposition: Admit to inpatient treatment Problem #1: psychosis Response to treatment: Worsening Medications, Labs and Plan: haldol 5mg PO BID, benadryl 25mg PO BID Therapy: Milieu/ brief supportive Consultations: n/a Risk: High due to psychotic features, NOT due to suicidal ideations. Justification for continued inpatient stay: Continued danger to self and/or others Continued behavior intolerable to patient or society High probability of danger to self or others recurring if patient were to be discharged, and imminent re-hospitalization likely
Goals of treatment while in inpatient: Increased level of functioning Reestablish healthy coping skills Identify external support system Increased self esteem Improved mood and affect Monitor medication compliance Develop effective social relationships Improve communications skills Decreased agitation if present Decreased delusional/paranoid thought pattern if present Provide safety for patients Decrease hallucinations if present Decrease feelings of suicidality if present upon admission COUNSELING/PSYCHOEDUCATION: Provided with: Patient Diagnostic results Risk and Benefits of treatment options Medication management including treatment options, potential benefits and side effects Importance of compliance with chosen treatment options Drug-drug interactions Risk factor reduction Prognosis Patient Instructions: Encouraged compliance with medications Benefits and side effects of medications re-discussed Encouraged reporting side effects to nursing and medical staff Nursing Instructions: Universal Social Work instructions: assessment for placement/aftercare Precautions: elopement / behavioral AIMS: AIMS (Mental Health Instrument) The patient was evaluated for symptoms of tardive dyskinesia using the AIMS.
Abnormal Involuntary Movement Scale
1) AIMS Muscles of Facial Expression : none
2) AIMS Lips and Perioral Area : none
3) AIMS Jaw Area Involuntary Movements : none
4) AIMS Tongue Involuntary Movements : none
5) AIMS Upper Arms, Wrists, Hands, Fingers : none
6) AIMS Lower Legs, Knees, Ankles, Toes : none
7) AIMS Neck, Shoulder, Hips : none
8) AIMS Overall Abnormal Movement Severity : none
Total score for items 1-7: 0
