Patient is a 15 year old transgender male to female with PPH of unspecified mood disorder, conduct disorder, exhibitionist behavior, and paraphilia who presented involuntary under PC for SI with plan to overdose on medications.
Per patient: Upon interview, patient states that he recently made a song about a former classmate that he had interpersonal conflict with. He states that at school yesterday, a friend of this former classmate confronted him regarding the song and patient subsequently punched him. He states that he later had a therapy appointment in which he expressed SI with plan to overdose on his psychotropic medications. Patient currently denies depressed mood or any other depressive symptoms besides intermittent SI. At this time, patient expresses SI but denies intent or plan. He is able to contract for safety on the unit. He denies AVH. No overt signs of mania or psychosis elicited. Patient states that he has been compliant with his medications since discharge from JBHH last month.
Per mother: She states that she was notified by patient's school that there was an incident in regards to something on social media which led to altercation between patient and another student. She states that patient then voiced SI with plan to overdose on medications when he returned home. She states that patient has been compliant with medications at home and has not voiced SI recently at home. She states that patient has been approved for residential program at Citrus, now pending available bed.
Quality: aggression, impulsivity, SI
Duration: days
Timing: acute on chronic
Severity: severe, interfering with daily functioning / interfering with safety of self or others
Context: precipitating stressor for admission
Modifying factors: medications, therapeutic milieu
Associated signs and symptoms: see HPI & MSE
Based on symptoms and behaviors described above:
-There is evidence of symptoms and behavior reflecting impairment, and continued treatment in an inpatient psychiatric setting is warranted at this time
-No less restrictive alternative is presently available
-Patient continues to meet criteria for inpatient admission to BH Unit
Past Psychiatric History
Inpatient treatment: Multiple hospitalizations at JBHH, most recently 12/9/21-12/13/21
Outpatient treatment: Yes, psychiatrist through Citrus and therapist through FACES program
Suicide History: two previous attempts by choking, hx of cutting forearm
Past psychiatric medications: Zyprexa, Abilify, Geodon, Latuda, Risperidone (s/e: increased breast size)
Current psychiatric medications: Lexapro 10mg, Depakote ER 500mg QAM and 750mg QHS, Seroquel 150mg BID
Medical History
Past medical history: denies
Past surgical history: denies
Seizures: denies
Loss of consciousness: denies
Traumatic brain injury: denies
Current nonpsychiatric medications: None
Allergies
Fish
Latuda
Substance Use History
Denies
Trauma History
Per chart, DCF case open: Frank (case manager 305-546-9279)
Physical: Yes
Sexual: denies
Neglect: denies
Family History
Mental illness: denies
Psychosocial History
Raised: mother
Siblings: 3
Lives with: mother and 3 siblings
Relationship: single
Educational History
Grade: 10th grade
Grades: Poor
Suspensions: Denies
Legal History
Legal guardian: mother
History of arrest: denies
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
Vital Signs
Temperature 36.6 (06:00)
Systolic Blood Pressure 127 (06:00)
Diastolic Blood Pressure 66 (06:00)
Pulse 79 (06:00)
SpO2 100 (06:00)
Respiratory Rate No result
Mental Status Exam
Appearance: adequate grooming and hygiene, appears older than stated age
Behavior: calm and cooperative with interview
Orientation: awake, alert, oriented to person, location, date, situation
Speech: normal rate and rhythm, appropriate volume, spontaneous, comprehensible
Eye Contact: good
Motor Activity: no PMA/PMR/AIMs noted
Mood: Euthymic
Affect: congruent, reactive, full range
Thought Process: organized, goal directed
Thought Content: no delusions, preoccupations, obsessions, compulsions, or phobias elicited
Suicidal Ideation/Thought/Intent/Plan: endorses SI, but denies current intent or plan
Homicidal Ideation/Thought/Intent/Plan: denies
Perceptual Disturbances: denies AVTOG hallucinations
Insight/Judgment: limited/limited
Attention/Concentration: fair/fair to interview
Memory: grossly intact
Medical Decision Making
DSM-5 Diagnosis:
Mood disorder, Unspecified F39
Conduct disorder F91.9
Exhibitionist behavior F65.2
Paraphilia, unspecified F65.9
Self-injurious behavior Z72.89
R/O Borderline personality disorder F60.3
Plan:
1. Occupational/Recreational/Activity Therapy: will participate
2. School: will attend
3. Information: previous records, patient, parent
4. Studies to be ordered:
5. Precautions: level 1
6. Individual sessions: psychoeducation, safety, coping skills
7. Family sessions: psychoeducation, safety, length of stay
8. Medications:
Medications (6) Active
Scheduled: (4)
divalproex 250 mg Tab ER 750 mg 3 tab, ORAL, BEDTIME
divalproex 500 mg Tab ER 500 mg 1 tab, ORAL, QAM
escitalopram 10 mg Tab 10 mg 1 tab, ORAL, DAILY
QUEtiapine IR 50 mg Tab 150 mg 3 tab, ORAL, BID
Continuous: (0)
PRN: (2)
magnesium hydrox (MOM) Liquid 30 mL 30 mL, ORAL, Q12H
nicotine 2 mg Loz 2 mg 1 lozenge, TRANSMUCOSAL, Q2H
9. Aftercare planning: medication management, individual therapy, family therapy,
10. Estimated length of stay: guarded
Patient seen and discussed with Dr. Parker and the treatment team.
The patient was assessed and was determined to be moderate suicide risk, but at high risk of self injurious behavior. The patient requires 1:1 sitter.
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.
Psychiatry Attending Attestation for Admission Notes
I performed a history and physical examination of the patient and discussed the management plan with the resident Dr. Pham
I reviewed the resident’s note and agree with the documented findings and plan of care for the diagnosis of :
Mood disorder, Unspecified F39
Conduct disorder F91.9
Exhibitionist behavior F65.2
Paraphilia, unspecified F65.9
Self-injurious behavior Z72.89
R/O Borderline personality disorder F60.3
imazdm25
HPI.docx
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