Assignment 2: Comprehensive Psychiatric Evaluation Note and Patient Case Presentation /PRAC 6645: Psychotherapy with Multiple Modalities Practicum Week 4
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HistoryofPresentIllness.docxHistory of Present Illness
Joshua Hyppolite is a 16 y/o boy with PMH of grave's disease and presumed autoimmune encephalitis (responded to IVIG and high dose steroids twice) who was transferred to CAP for severe agitation/psychiatric stabilization. (please refer to pediatric discharge note dated 11/16 for full interval history)
Patient was seen this morning, the chart was reviewed, and the case was discussed with the ancillary staff.
Per MAR review, the patient has shown good compliance with medications but required PRN of Thorazine 50 mg IM yesterday for agitation.
Patient seen in his room. He remained to be disorganized in speech and behavior, screaming obscenities. Patient also found to be excessively drooling. Patient denied mood symptoms of depression or mania. Patient denies AH, VH and does not endorse gross delusions. Patient adamantly denied past and current suicidal and homicidal ideation, plan, intent or attempt.
Target Symptoms
Quality - psychosis/delirium/aggression
Duration - acute
Timing - constant
Severity - severe
Interferes with daily activities - yes
Interferes with safety of self or others - yes
Context - exacerbation of psychosis/encephalopathy
Modifying factors - medications, rest, psychosocial support
Associated signs and symptoms - disorganized behavior, aggression/violence, RTIS, agitation/pacing, confusion
Psychiatric History
Inpatient treatment: admitted a few days prior to readmission after being sent to Holtz for medical tx
Outpatient treatment: none
Suicide History: none
Past psychiatric medications: haldol, risperidone, ativan
Current psychiatric medications: Risperidone
Medical History
Past medical history: Grave's disease, NMDA Encephalitis
Past surgical history: denies
Seizures: denies
Loss of consciousness: denies
Traumatic brain injury: denies
Current nonpsychiatric medications: Prednisone, levofloxacin, rivaroxaban
Allergies
NKDA
Substance Use History
Tobacco: denies
Alcohol: denies
Cannabis: denies
Cocaine: denies
Opioids: denies
Benzodiazepines: denies
Amphetamines: denies
Hallucinogens: denies
Detox/Rehab: denies
Trauma History
Physical: denies
Sexual: denies
Neglect: denies
Family History
Mental illness: denies
Suicide attempts: denies
Substance abuse: denies
Medical problems: denies
Psychosocial History
Born: Bahamas
Raised: Bahamas
Lives with: family
Legal History
Legal guardian: parents_
History of arrest: none
Social History
Abuse/Neglect/Domestic Violence
Injuries/Abuse in household: No apparent signs of abuse. Hit, slapped, kicked, punched, choked, or physically hurt you: No apparent signs of abuse. Threatened you or made you feel afraid: No apparent signs of abuse. Touched you or forced you to have sex in a way you did not want: No apparent signs of abuse. Refused you food, medicines, or medical aids: No apparent signs of abuse. Feels safe at home: Yes. Safe place to go: Yes., 11/16/2021
Injuries/Abuse in household: No. Type of Injuries/Abuse/Neglect: none. Hit, slapped, kicked, punched, choked, or physically hurt you: No. Threatened you or made you feel afraid: No. Touched you or forced you to have sex in a way you did not want: No. Refused you food, medicines, or medical aids: No. Feels safe at home: No. Safe place to go: No. Agency(s)/Others notified: No. Agencies notified: None. Police Case Number none. Emotional help family/friends available: No. Chronically ill or terminally ill with frequent visits No., 08/11/2021
Alcohol
Use: Denies alcohol use., 11/16/2021
Use: Denies alcohol use., 08/11/2021
Electronic Cigarette/Vaping
Use: Never., 11/16/2021
Use: Never., 08/11/2021
Substance Abuse
Use: Denies substance abuse., 11/16/2021
Use: Denies substance abuse., 08/11/2021
Tobacco
Never tobacco user, Never, 11/16/2021
Never tobacco user, Never, 09/09/2021
none, Never tobacco user, Never, 08/11/2021
Problem List/Past Medical History
Ongoing
No chronic problems
Historical
No qualifying data
Review of Systems
Review Of Systems:
1. Neurological- negative
2. Integumentary- negative
3. Cardiovascular- negative
4. Respiratory- negative
5. Endocrine- negative
6. Gastrointestinal- sialorhea
7. Genitourinary- negative
8. Hematologic- negative
9. Immunologic- negative
10. ENT- negative
11. Ophthalmologic- negative
12. MSK- negative
**Patient has no new physical or medical complaints or concerns at this time.
Allergies
NKA
Medications
Inpatient
Ativan, 1 mg= 1 tab, ORAL, TID
Benadryl, 50 mg= 1 cap, ORAL, BID
Benadryl, 50 mg= 1 mL, IM, Q6H, PRN
chlorproMAZINE- ETO, 50 mg= 2 mL, IM, Q6H, PRN
influenza virus vaccine, inactivated, 0.5 mL, IM, BEFORE DISCHARGE
levoFLOXacin, 750 mg= 3 tab, ORAL, DAILY
predniSONE, 20 mg= 1 tab, ORAL, DAILY
RisperDAL, 3 mg= 1 tab, ORAL, BEDTIME
RisperDAL, 2 mg= 1 tab, ORAL, QAM
ThoRAZine, 50 mg= 2 mL, IM, Q6H, PRN
Xarelto, 20 mg= 1 tab, ORAL, BEDTIME
Home
Aquaphor, 1 app, TOPICAL, QID
Benadryl 25 mg oral capsule, 50 mg= 2 cap, ORAL, BID, 1 refills
cholecalciferol 1000 intl units oral tablet, 25 mcg= 1 tab, ORAL, DAILY, 1 refills, Not taking
influenza virus vaccine, inactivated, IM, BEFORE DISCHARGE
levoFLOXacin 750 mg oral tablet, 750 mg= 1 tab, ORAL, DAILY
MiraLax oral powder for reconstitution, 17 g, ORAL, DAILY
risperiDONE 1 mg oral tablet, 2 mg= 2 tab, ORAL, BID, 3 refills
Xarelto 20 mg oral tablet, 20 mg= 1 tab, ORAL, BEDTIME
Immunizations
Vaccine
Date
Status
influenza virus vaccine, inactivated-FLU - Not Given
Comments :
Family or Guadian Refuses
influenza virus vaccine, inactivated-FLU - Not Given
Comments :
Family or Guadian Refuses
poliovirus vaccine, inactivated-IPV 08/19/2009 Recorded
measles/mumps/rubella virus vaccine-MMR 08/19/2009 Recorded
diphtheria/pertus,acel/tetan pedia(Dtap) 08/19/2009 Recorded
diphtheria/pertus,acel/tetan pedia(Dtap) 10/04/2006 Recorded
measles/mumps/rubella virus vaccine-MMR 11/16/2005 Recorded
poliovirus vaccine, inactivated-IPV 06/22/2005 Recorded
hepatitis B pediatric vaccine 06/22/2005 Recorded
diphtheria/pertus,acel/tetan pedia(Dtap) 06/22/2005 Recorded
poliovirus vaccine, inactivated-IPV 04/27/2005 Recorded
hepatitis B pediatric vaccine 04/27/2005 Recorded
diphtheria/pertus,acel/tetan pedia(Dtap) 04/27/2005 Recorded
poliovirus vaccine, inactivated-IPV 03/02/2005 Recorded
hepatitis B pediatric vaccine 03/02/2005 Recorded
diphtheria/pertus,acel/tetan pedia(Dtap) 03/02/2005 Recorded
Vital Signs/Measurements/Pain Intensity:0 (No Pain) - 10 (Extreme Pain)
Height: 170 cm
Weight: 79.7 kg
Temperature Oral: 36.5 DegC
Peripheral Pulse Rate: 123 bpm High
Respiratory Rate: 18 br/min
Systolic Blood Pressure: 122 mmHg
Diastolic Blood Pressure: 90 mmHg High
Pain Present: No actual or suspected pain
Latest Vitals
Temperature 36.5 (06:54)
Systolic Blood Pressure 122 (06:54)
Diastolic Blood Pressure 90 (06:54)
Pulse 123 (06:54)
SpO2 No result
Respiratory Rate 18 (06:54)
Lab Results
Last Month
Basic Metabolic Panel: Hematology:
Sodium: 138 mmol/L (11/13/21) Hemoglobin: 14.4 g/dL (11/17/21)
Potassium: 4.2 mmol/L (11/13/21) : ()
: () WBC Count: 7.4 x10(3)/mcL (11/17/21)
Magnesium Level: 2.1 mg/dL (11/13/21) Platelet Count: 396 x10(3)/mcL (11/17/21)
Blood Urea Nitrogen: 8 mg/dL (11/13/21) INR POC: ------
Creatinine POC: 0.80 mg/dL (11/13/21)
: ()
Urinalysis:
: () Urine Blood: Neg mg/dL (11/14/21)
Nitrites: Neg (11/14/21) Protein: Neg (11/14/21)
Ketones: Neg mg/dL (11/14/21) Urine Color Urine Dipstick: ------
Leukocyte Esterase: Neg (11/14/21) : ()
Bilirubin: Neg mg/dL (11/14/21) Urine pH: 6.5 (11/14/21)
Urobilinogen: Negative mg/dL (11/14/21) Specific Gravity: 1.010 (11/14/21)
Additional - Last Month
Absolute Basophil: 0.02 x10(3)/mcL (11/17/21) Absolute Eosinophil: 0.01 x10(3)/mcL (11/17/21) Absolute Immature Granulocyte: 0.02 x10(3)/mcL (11/17/21)
Absolute Lymphocyte: 0.4 x10(3)/mcL (11/17/21) Absolute Monocyte: 0.2 x10(3)/mcL (11/17/21) Absolute Neutrophil: 6.7 x10(3)/mcL (11/17/21)
Adenovirus: Not Detected (11/12/21) Albumin Level: 4.5 g/dL (11/13/21) Alkaline Phosphatase: 58 unit/L (11/13/21)
ALT (SGPT): 26 unit/L (11/13/21) Anion Gap: 9 (11/13/21) APTT: 30 second(s) (11/12/21)
AST (SGOT): 70 unit/L (11/13/21) Bacteria: 0 (11/14/21) Basophil (%): 0.3 % (11/17/21)
Bordetella Parapertussis: Not Detected (11/12/21) Bordetella pertussis: Not Detected (11/12/21) C-Reactive Protein: 4.7 mg/dL (11/06/21)
Calcium Level: 10.0 mg/dL (11/13/21) Chloride: 102 mmol/L (11/13/21) Clarity: Clear (11/14/21)
Color: Colorless (11/14/21) Coronavirus 229E: Not Detected (11/12/21) Coronavirus HKU1: Not Detected (11/12/21)
Coronavirus NL63: Not Detected (11/12/21) Coronavirus OC43: Not Detected (11/12/21) CPK: 756 unit/L (11/13/21)
D DIMER Quantitation: 1.67 mcg/mL FEU (11/12/21) DRVV (Lac) Ratio: 1.31 (11/15/21) eGFR (African-American): 152 (11/13/21)
eGFR (Non African-American): 131 (11/13/21) Eosinophil (%): 0.1 % (11/17/21) ESR: ESR (11/04/21)
Fibrinogen: 202 mg/dL (10/27/21) Flu A: Not Detected (11/12/21) Flu B: Not Detected (11/12/21)
Glucose: 93 mg/dL (11/13/21) Glucose: Negative mg/dL (11/14/21) Hematocrit: 42.7 % (11/17/21)
Hu Ab, IFA, CSF: NEGATIVE (10/20/21) Human Metapneumovirus: Not Detected (11/12/21) Immature Granulocyte (%): 0.3 % (11/17/21)
Influenza A Ag: Not Detected (11/12/21) Influenza B Ag: Not Detected (11/12/21) INR: 1.18 (11/17/21)
Interpretive Results Table: Interpretive Results Table (10/22/21) Ionized Calcium: 1.22 mmol/L (10/27/21) LDH: 867 unit/L (11/06/21)
Lupus Result: Positive (11/15/21) Lymphocyte (%): 5.8 % (11/17/21) MCH: 29.3 pg (11/17/21)
MCHC: 33.7 g/dL (11/17/21) MCV: 87.0 fL (11/17/21) Monocyte (%): 2.7 % (11/17/21)
MPV: 12.1 fL (11/17/21) Mycoplasma pneumoniae: Not Detected (11/12/21) Neocomplete Comments: Neocomplete Comments (10/22/21)
Neuron Specific Enolase: 7.8 nanogram/mL (11/09/21) Neutrophil (%): 90.8 % (11/17/21) NRBC%: 0.0 /100WBC (11/17/21)
NRBC(Abs): 0.00 x10(3)/mcL (11/17/21) NT-proBNP: 30.5 pg/mL (11/12/21) Order Result: See Note (10/18/21)
Osmolality Calculated: 274 mOsm/kg (11/13/21) Parainfluenza 1 (PIV1): Not Detected (11/12/21) Parainfluenza 2 (PIV2): Not Detected (11/12/21)
Parainfluenza 3 (PIV3): Not Detected (11/12/21) Parainfluenza 4 (PIV4): Not Detected (11/12/21) Phosphorous: 4.8 mg/dL (11/06/21)
Prothrombin Time: 14.9 second(s) (11/17/21) QFT- Nil: 0.02 Int_Unit/mL (11/04/21) QFT-Mitogen minus Nil: >10.00 Int_Unit/mL (11/04/21)
QFT-TB1 minus Nil: 0.00 Int_Unit/mL (11/04/21) QFT-TB2 minus Nil: 0.00 Int_Unit/mL (11/04/21) QuantiFERON TB Plus: Negative (11/04/21)
QuantiFERON TB Plus Interp: QuantiFERON TB Plus Interp (11/04/21) RBC Count: 4.91 x10(6)/mcL (11/17/21) RDW-CV: 12.8 % (11/17/21)
Respiratory Syncytial Virus: Not Detected (11/12/21) Rhinovirus/Enterovirus: Not Detected (11/12/21) RSV: Not Detected (11/12/21)
SARS CoV 2 Interp: SARS-CoV-2 RNA is Not Detected (11/15/21) SARS CoV 2 RNA, RT PCR: Not Detected (11/15/21) Silica Clotting Test Ratio: 0.95 (11/15/21)
Slide Review: Not Indicated (11/17/21) Squamous Epithelial Cell: <1 (11/14/21) STACLOT LA Clotting Time: 2.9 second(s) (11/15/21)
Summary Interpretation: Summary Interpretation (10/22/21) Thrombin Time: 13.7 second(s) (11/15/21) Total Bilirubin: 0.6 mg/dL (11/13/21)
Total CO2 Content: 27 mmol/L (11/13/21) Total Protein: 8.4 g/dL (11/13/21) Troponin I: <0.012 ng/mL (11/12/21)
TSH: 1.240 mcIU/mL (11/04/21) Uric Acid: 5.5 mg/dL (11/06/21) Urine Microscopic: Not Indicated (11/14/21)
Urine RBC's: 1 /HPF (11/14/21) Urine WBC's: <1 /HPF (11/14/21) Viral Respiratory Panel PCR Comment: See Comment (11/12/21)
Mental Status Exam
Level of Consciousness: Alert
Mood: Anxious
Delusions: Thought Blocking
Hallucinations Present: Unable to assess
Mood MH: Anxious
Insight MH: Poor
Judgement MH: Poor
Thought Process: Echolalia, Loose Associations
Appearance BH: Bizarre
Insight: Poor
Speech BH: Echolalia, Loud, Spontaneous
Interaction BH: Avoids interaction
Affect Range: Appropriate Range
Affect Quality: Irritable
Affect Congruence: Congruent with mood
Memory Crisis: Other: not intact
Concentration: Disorganized
Thought Content: Unable to assess
Columbia Suicide Severity Rating Scale
CSSRS Ongoing Screen Suicide Behavior: No (11/16/21 16:00:00)
Ongoing Suicide Screening Risk Level: Low risk (11/16/21 16:00:00)
CSSRS Protective Factors Recent: Belief that suicide is immoral; high spirituality, Engaged in work or school, Fear of death or dying due to pain and suffering, Identifies reasons for living, Supportive social network or family, Engaged in treatment (11/16/21 16:00:00)
CSSRS Screen Wish to be Dead: No (11/16/21 15:04:00)
CSSRS Screen Suicidal Thoughts: No (11/16/21 16:00:00)
CSSRS Screen Suicide Behavior: No (11/16/21 15:04:00)
Suicide Screening Risk Level: No Risk Factors Identified (11/16/21 15:04:00)
Treatment and Recommendation
1. Patient continues to require 24-hour observation, nursing care, and inpatient treatment and cannot be treated in a less restricted environment.
2. Complexity of data: Reviewed clinical labs. Reviewed imaging results. Old records reviewed. Case discussed with other medical providers
3. Nursing orders: Encourage compliance with treatment plan, ADLs, groups.
4. Medication:
Medication List
Active Medications
Ordered
atropine ophthalmic: 1 drop, BUCCAL, QID.
chlorproMAZINE: 50 mg, 2 mL, IM, Q6H, PRN: Agitation.
diphenhydrAMINE: 50 mg, 1 cap, ORAL, BID.
diphenhydrAMINE: 50 mg, 1 mL, IM, Q6H, PRN: Agitation.
influenza virus vaccine, inactivated: 0.5 mL, IM, BEFORE DISCHARGE.
LORazepam: 1 mg, 1 tab, ORAL, TID.
predniSONE: 20 mg, 1 tab, ORAL, DAILY.
risperiDONE: 3 mg, 1 tab, ORAL, BEDTIME.
risperiDONE: 3 mg, 1 tab, ORAL, QAM.
rivaroxaban: 20 mg, 1 tab, ORAL, BEDTIME.
Prescribed
cholecalciferol: 25 mcg, 1 tab, ORAL, DAILY, for 30 day(s), with
food, 30 tab, 1 Refill(s).
diphenhydrAMINE: 50 mg, 2 cap, ORAL, BID, for 90 day(s), 360 cap, 1
Refill(s).
polyethylene glycol 3350: 17 g, ORAL, DAILY, for 14 day(s), keep
taking until having loose stools, 255 g, 0 Refill(s).
risperiDONE: 2 mg, 2 tab, ORAL, BID, for 90 day(s), 360 tab, 3
Refill(s).
rivaroxaban: 20 mg, 1 tab, ORAL, BEDTIME, for 90 day(s), 90 tab, 0
Refill(s).
Documented
emollients, topical: 1 app, TOPICAL, QID.
influenza virus vaccine, inactivated: IM, BEFORE DISCHARGE.
Medications Inactivated in the Last 72 Hours
chlorproMAZINE: 50 mg, 1 tab, ORAL, TID, PRN: Agitation.
chlorproMAZINE: 25 mg, 1 mL, 50 mL/hr, IV, ONCE, PRN: Agitation.
chlorproMAZINE: 25 mg, 0.5 tab, ORAL, ONCE, PRN: Agitation.
chlorproMAZINE: 50 mg, 2 mL, IM, Q6H, PRN: See MH ETO Restrain
Seclusion Form.
chlorproMAZINE: OVERRIDE, ONCE.
diphenhydrAMINE: 50 mg, 1 mL, IV PUSH, Q4H, PRN: Agitation.
diphenhydrAMINE: 50 mg, 1 mL, IV PUSH, Q12H.
diphenhydrAMINE: 50 mg, 1 mL, IV, BID.
diphenhydrAMINE: 50 mg, 1 cap, ORAL, BID.
diphenhydrAMINE: 50 mg, 2 cap, ORAL, BID, PRN: Insomnia.
enoxaparin: 80 mg, 0.8 mL, SUBCUTANEOUS, Q12H.
haloperidol: 5 mg, 1 mL, IM, Q4H, PRN: Agitation.
haloperidol: 10 mg, 2 mL, IM, Q12H.
influenza virus vaccine, inactivated: 0.5 mL, IM, BEFORE DISCHARGE.
levoFLOXacin: 750 mg, 1 tab, ORAL, DAILY.
levoFLOXacin: 750 mg, 1 tab, ORAL, DAILY, for 2 day(s), 2 tab, 0
Refill(s).
levoFLOXacin: 750 mg, 3 tab, ORAL, DAILY.
levoFLOXacin: OVERRIDE, ONCE.
LORazepam: 2 mg, 1 mL, IV, Q4H, PRN: Agitation.
LORazepam: 2 mg, 1 mL, IM, Q4H, PRN: Agitation.
predniSONE: 20 mg, 1 tab, ORAL, DAILY.
predniSONE: 20 mg, 1 tab, ORAL, DAILY.
predniSONE: 20 mg, 1 tab, ORAL, DAILY.
risperiDONE: 2 mg, 2 tab, ORAL, BID.
risperiDONE: 2 mg, 1 tab, ORAL, BID.
risperiDONE: OVERRIDE, ONCE.
risperiDONE: 1 mg, 1 tab, ORAL, ONCE.
rivaroxaban: 15 mg, 1 tab, ORAL, BID.
rivaroxaban: 20 mg, 1 tab, ORAL, BEDTIME.
5. Patient Instructions: Encouraged compliance with medications, Benefits and side effects of medications were discussed, Encouraged reporting side effects to nursing and medical staff
6. Social work evaluation for disposition and follow up
Assessment/Plan
Psychosis F29
Psychiatry Attending Attestation for Admission Notes
I performed a history and physical examination of the patient Joshua Hyppolite and discussed the management plan with the resident Dr. Alrojolah
I reviewed the resident’s note and agree with the documented findings and plan of care for the diagnosis of Psychosis
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.
low suicide risk
Ordered:
Consult Pediatric Neurology, 11/17/2021 09:03:00 EST, Routine, Continued AMS in the setting of likely underlying medical etiology, Assume concurrent care, orders permit, 7865538009, BH Children's Unit, Psychosis
Orders:
chlorproMAZINE, 50 mg = 2 mL, IM, Form: Inj, Q6H, PRN Agitation, First Dose: 11/17/2021 10:20:00 EST
diphenhydrAMINE, 50 mg = 1 mL, IM, Form: Inj, Q6H, PRN Agitation, First Dose: 11/17/2021 10:20:00 EST
Complete Blood Count w/ Platelets, 11/17/2021 09:28:00 EST, Routine, Blood, 11/17/2021 11:00:00 EST
Comprehensive Metabolic Panel, 11/17/2021 09:28:00 EST, Routine, Blood, 11/17/2021 11:00:00 EST
PT INR, 11/17/2021 09:28:00 EST, Routine, Blood, 11/17/2021 11:00:00 EST
