Duration of Session: 50 Minutes
General Information Given by: Patient
Information Given by: Patient
Legal Status: Voluntary
Chief Complaint:
Reason for Admission: (from crisis unit provider on 07-11-22 at 14:57 )
Patient is a 27 year old male with PPHx of schizoaffective disorder, polysubstance abuse (marijuana, cocaine), medication noncompliance presents involuntarily to Crisis via Ex-Parte by patient's mother for aggressive behavior and psychotic symptoms. Mother is listed as patient's legal guardian. History of multiple hospitalizations at JBHH, last here from 04/04-04/19 with similar presentation. On exam, patient is found sitting calmly in the milieu, grossly delusional, disorganized thought process, perseverating on taking his medications and being discharged. Patient states his name is Bodi, he is 41 years old, and is here because his "daughter" wants him to take his medications. Denies SI/HI/AVH. No evidence of depression, mania, intoxication/withdrawal. Patient required ETO (Haldol 5 mg, Ativan 2 mg, Benadryl 50 mg) while on unit due to agitated behavior, threatening towards staff.
Per patient's mother ,patient is noncompliant with his medications, does not care for himself, actively psychotic and fears for her safety. She reports that he is frequently walking around with a knife in his hand saying he is going to kill her. She states she can no longer live like this and does not want him discharged home to her. She reports she has video evidence of his aggressive behavior and would provide it if helpful to his management. She reports that patient is severely delusional as patient believes that his mother is his daughter.
HPI:
This is a 27 year old male with priorbehavioral health history of Schizoaffective disorder, and SUD that was brought in to the JMHBH ED by police ex partee due to psychosis. The patient was aggressive with the mother. The patient has multiples admissions for similar behavior, non-compliant with medications. The patient has history of State Hospital for 6-months. He is also pending of charge for aggression on the street (as per mother statement). Upon arrival to the crisis unit, this patient initial presentation consisted of aggressive behavior toward staffing, requiring the administration of a ETO. In the unit the patient seen and evaluated in the common area requesting a discharge, perseverations, delusional thinking about her mother that is his daughter. The LG was contacted (mother) and she is coming in the evening today to sign for medications and treatment.
Target Symptoms:
Quality –psychosis,
Duration –days to weeks
Timing –increasing
Severity - mild
Context –adjustment in medications,
Modifying factors:
Aggravating: medication noncompliance,
Alleviating: hospitalization, compliance with medications , good sleep hygiene
Interfering with daily functioning: Yes
Interfering with safety of self/others: Yes
Causing self-neglect: Yes
Associated signs and symptoms:
· Suicidal ideation –No
· Command type hallucination –No
· Delusions –Yes
· Depression/helplessness/hopelessness –No
· Sleep disturbances –No
Past Psychiatric History:
Past inpatient hospitalizations: Multiple previous JBHH admissions
Past state hospitalizations: yes
Past outpatient: private provider (patient don't recall name)
Compliance: non-compliance
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
If yes Counseling provided during the hospital stay N/A.
Was nicotine replacement therapy provided: N/A
Patient received nicotine replacement therapy. N/A
Patient declined nicotine replacement therapy N/A
Allergy to all FDA-approved tobacco cessation medications. N/A
FDA smoking cessation medication: None
Past Marchman Act: No
Past Rehabilitation Unit admissions: Yes
Past Detoxification Unit admissions: No
Past Outpatient Substance Use: No
AA/NA participation: No
Compliance: N/A
Past Medical History:
TBI / LOC / Black outs: None
Seizures: No
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:
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: would not elaborate as to specific family member.
Suicide attempts: denies
Substance abuse: denies
Medical problems: denies
Dementia: denies
Social/Legal History:
Legal: Pending charges
Employment:Unemployed
living situation: with parents
support system: Fair
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: limited hygiene and groomed
Attitude toward examiner: demanding defensive,
Alert and oriented : to person time, place,
Eye contact: normal
Speech: pressured
Mood: elevated
Affect: labile
Thought process: Disorganized, tangential
Thought content: delusions
Perceptual disturbances: None
Suicidal ideation/intention/plan: No
Homicidal ideation/intention or plan: No
Insight: lnone insight
Judgement: dangerous
Attention and Concentration: fair
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
Medications:
Medication List
Active Medications
Ordered
Al hydroxide/Mg hydroxide/simethicone: 30 mL, ORAL, Q6H, PRN:
Dyspepsia.
diphenhydrAMINE: 50 mg, 1 mL, IM, Q4H, PRN: See MH ETO Restrain
Seclusion Form.
haloperidol: 5 mg, 1 mL, IM, Q4H, PRN: See MH ETO Restrain Seclusion
Form.
LORazepam: 2 mg, 1 mL, IM, Q4H, PRN: See MH ETO Restrain Seclusion
Form.
magnesium hydroxide: 30 mL, ORAL, Q12H, PRN: Constipation.
nicotine: 2 mg, 1 lozenge, TRANSMUCOSAL, Q2H, PRN: See Comment.
Medications Inactivated in the Last 72 Hours
diphenhydrAMINE: OVERRIDE, ONCE.
haloperidol: OVERRIDE, ONCE.
LORazepam: OVERRIDE, ONCE.
Immunizations:
No Immunizations Documented This Visit
Vital Signs/Measurements/Pain Intensity:Vitials/Ht/Wt
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Height Description: Estimated
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Height: 180.3 cm
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Weight Description: Estimated
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Weight: 70 kg
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Body Mass Index: 21.53
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Temperature Oral: 36.4 DegC Low
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Peripheral Pulse Rate: 95 bpm
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Respiratory Rate: 18 br/min
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Systolic Blood Pressure: 132 mmHg
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Diastolic Blood Pressure: 79 mmHg
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SpO2: 100 %
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Lab Results:
Diagnosis:
Schizoaffective disorder, unspecified (F25.9)
Assessment/Plan:
Disposition: Admit to inpatient treatment
Problem #1: psychosis
Response to treatment: Worsening
Medications, Labs and Plan: Haldol and Will consider the use of a LAI during the course of present admission.
Problem #2: mania / Mood dysregulation
Response to treatment: Worsening
Medications, Labs and Plan: Depakote
Therapy: Milieu/ brief supportive
Consultations: n/a
Risk: low , No suicidal ideations.
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
Precaution: behavioral observation
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DurationofSession.docx
