Jaspreet Kaur Sra
PSYCH Rotation AT QHC
May 16, 2022
Name: TP
DOB: xx/xx/1994
Race: African American
Sex: female
Date: April 17, 2021
Time: 9:00am
Source of information: Self, sister
Reliability: reliable
Location: QHC CPEP
Mode of transport: public transportation
Referral: self
Chief Complaint: “I feel like a horrible person and disappointment to everyone”
Patient is a 27 year old female single, employed, student at QCC domiciled with mother with a prior psychiatric history of depression BIB self with complaint of suicidal thoughts and worsening depression over the past 2 years. Patient walked into the MER requesting help becasue she was feeling depressed, overwhelmed and having suicidal thoughts, wanting to kill herself. Patient states she started treatment by a psychiatrist ~3 years ago and was taking Prozac. However, since the pandemic she stopped following up and has not taken the medication. She states states she has had suicidal thoughts in the past and did cut but stopped cutting in the 9th grade and denies attempts currently. She reports that she currently feels she is a “horrible person” and has let her family down. She states her mother and father have health problems (Mom: cataract in one eye and Dad: ESRD on dialysis) and that she is the only child that takes care of them. They recently divorced which has made it more difficult for her to take care of them. She has many responsibilities and her siblings do not help her out. She states she has difficulty concentrating and had to withdraw this semester. She is observed crying and labile in CPEP. Patient states her depression and anxiety is “very severe” and she has depressive symptoms of sadness, sleep and appetite disturbance and feels hopeless and helpless at times. She reports she plans to commit suicide by August 2022, as she feels by then she “will feel ready to go away.” She denies auditory or visual hallucination and homicidal ideation. She reports cannabis use occasionally but denies alcohol use or any other illicit drug use.
Patient provided sister D, ###-###-#### as collateral who reports the patient takes care of her parents and that the patient has been stressed and depressed. Patient told her sister she doesn’t want to be in New York anymore as it is affecting her ability to function. She states the patient was going on vacation with a friend but had to cancel due to financial reasons and believes this triggers her to have suicidal ideation.
PMHx
Depression
PSHx
Denies
Allergies
NKDA
Medications
Denies
Family History
Mother- Alive, HTN, HLD, cataract in right eye
Father – Alive. DM II , HTN, ESRD on dialysis
Sister #1 – no known medical history
Sister #2- no known medical history
Brother – no known medical history
Social History
- Patient works as a receptionist at a dental office
- She lives with her mother, two younger sisters and one younger brother
- She is not married and has no children
- She is currently sexually active with one male, denies history of STIs
- She denies recent travel
- She has a gym membership but has not gone to the gym in over 3 months
- She smokes marijuana occasionally. Denies alcohol or any other illicit drug use
- She sleeps on average 5 hours with some nights she does not sleep at all
- Her siblings cook food at home and she avoids fast food
Review of Systems
Constitutional: Negative for chills, diaphoresis and fever.
Respiratory: Negative for cough, chest tightness, shortness of breath and wheezing.
Cardiovascular: Positive for palpitations. Negative for chest pain and leg swelling.
Gastrointestinal: Positive for abdominal pain. Negative for abdominal distention, diarrhea, nausea and vomiting.
Genitourinary: Negative for decreased urine volume, difficulty urinating, dysuria, flank pain, frequency, hematuria and urgency.
Neurological: Negative for dizziness, tremors, seizures, syncope, facial asymmetry, speech difficulty, weakness, light-headedness, numbness and headaches.
Psychiatric/Behavioral: Positive for dysphoric mood, suicidal ideation and patient is nervous/anxious.. Negative for agitation, behavioral problems, confusion, hallucinations, hyperactivity.
Physical Exam
General – loss of appetite but no recent weight loss or gain, weakness/fatigue, fever or chills, night sweats, not in acute distress, not ill appearing, toxic appearing
Skin hair and nails – No excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution, changes in texture, open wounds
Pulmonary System
No dyspnea, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND, acid reflux
Cardiovascular System
No chest pain, HTN, edema, syncope, known heart murmur
Psychiatric
Disorganized, paranoid. No sign of anxiety, obsessive/compulsive disorder.
Neurological: No focal deficit present. alert and oriented to person, place, and time.No cranial nerve deficit.
Vital Signs Vitals WNL
o BP 114/72 mmHg sitting
o Pulse 95 bpm regular
o Temperature 36.8 °C oral
o Respiratory rate 16 unlabored
o O2 Sat 100% on room air
o Height: 63”
o Weight: 125 lbs
o BMI = 21.1
Mental Status Exam
General
- Appearance – TP is a petit African American female with long hair who appears well groomed. She is dressed in appropriate attire and appears well nourished with good hygiene. She appears her stated age and does not appear to have any acute wounds or injuries.
- Behavior and psychomotor activity – Upon evaluation the patient is seated cooperative but appears restless as she fidgets with her fingers and bites her fingernails. She does not appear to have any tics, tremors, retardation
- Attitude towards Examiner – Patient is calm, cooperative, responds to all questions appropriately. She does not appear guarded, maintains eye contact. She does not display any hostility or aggression towards the examiner or other staff. She established a rapport with the examiner in a few minutes.
Sensorium and Cognition
- Alertness and consciousness – patient was conscious and alert throughout interview
- Orientation – patient was oriented to time of day, year and setting of exam
- Concentration and Attention – Patient remained concentrated throughout the interview, was not distracted, internally preoccupied . She answered all questions appropriately.
- Capacity to read and write – average reading and writing ability displayed upon signing of admission documents
- Abstract Thinking – TP displayed intact abstract thinking after she was able to interpret commonly used English metaphors such as “ The grass is always greener on the other side” – What other people have always seems more appealing and fun, but that does not mean it will make you happier.
- Memory – Recent memory intact as she was able to recall her sisters telephone number, the medication she was taking 2 years ago and the events that occured prior to her coming to the hospital.
- Fund of information and knowledge – Patients intellectual performance was average and consistent with her level of education
Mood Affect
- Mood – The patient’s mood is depressed. She would face down during the interview and begin to tear when speaking about her parents and their health condition.
- Affect – Dysphoric affect, Labile as she is seen laughing and talking with other patients but tearful and sad during other instances. She is not guarded or constricted
- Appropriateness – mood and affect were congruent throughout the interview
Motor
- Speech – TPs, tone of speech was low and soft but rate, rhythm of speech were within normal limits. Her speech was coherent and her answer latency was within normal limits. .
- Eye Contact – Patient maintained good eye contact throughout the interview but would occasionally look on the floor when answering questions
- Body Movements – fluid motor movement. No tics or unintentional body movements.
Reasoning and Control
- Impulse control – patient displays inadequate impulse control. She reports suicidal ideation and does not have a specific plan but intends to do it will do it by August. She denies homicidal ideation/ plan or intent.
- Judgment –Patient denies current paranoia, delusions and auditory/ visual hallucinations. Judgment is impaired as she plans to comit suicide by August. However, she understands her thoughts of suicide are harmful which is why she brought herself to the hospital.
- Insight – Patient has inappropriate insight as she believes she is aware she has thoughts of sucide but does not want to be admitted to the hospital.
Assessment:
Patient is 27 year old African American female with a prior psychiatric history of depression who presents to the facility for complaint of suicidal ideation. Upon evaluation the patient is cooperative but restless, tearful with soft and slow speech and somewhat disorganized thought process. She reports feeling anxious and overwhelmed with the responsibilities she has. Patient has not been compliant with Prozac x1.5 years. Patient exhibits poor impulse control, judgment, and insight. Patient is currently at risk to harm self thus warrants admission to CPEP for observation and stabilization.
Differential Diagnosis
- Major Depressive Disorder: Patient was previously diagnosed with MDD and not been compliant with her medication. Patient states she is experiencing worsening depressive symptoms including feelings of hopelessness, helplessness, decreased concentration and depressed mood. She is not exhibiting signs of psychosis. She used to take Prozac but has not been compliant with the medication. It is likely that she is having MDD secondary to medication non compliance.
- Adjustment Disorder: Her parents recently divorced and she has been taking care of both of them causing her to be stressed. She reported how more difficult it has gotten to take care of both her parents as she needs to take her dad to dialysis and her mom has difficulty seeing from one eye.
- Cyclothymic Disorder: Patient is currently in a depressed mood, which she has reported for past few years. However, manic symptoms are unlikely as the patient nor sister mentioned such symptoms.
- Persistent Depressive Disorder: Patient reports feeling depressed for the past 2 years. She states loss of appetite, low self esteem and hopelessness. However, manic and hypomanic episodes need to be ruled out prior to making this diagnosis.
Diagnosis : Major Depressive Disorder
PLAN:
1. Admit to CPEP under Mental Hygiene For further evaluation, observation and stabilization.
2. Review labs, and review chart. Pt was provided with a urine specimen container and encouraged to provide UTOX and UA.
3. Remeron 15 mg at bedtime
4. Review medications and collateral information.
5. Order stat medication if needed.
6. q 15 min observation for patient safety
7. Re-evaluation of patient in AM.
Morning Re-evaluation Day 2
Upon psych evaluation, the patient is alert and AOx3/3 and cooperative, with depressed mood, soft and slow speech, and somewhat disorganized thought process and illogical. Patient presented with hopelessness,insomnia and suicidal thoughts. She reports she is feeling better and slept well throughout the night. She was seen being talkative and laughing with other patients. Patient exhibits poor impulse control, judgment, and insight. Patient denies previous hospitalizations. Patient is currently at risk to harm self thus warrants admission to CPEP for observation and stabilization. Patient was started on Remeron 15 mg nightly in cpep and was educated on the risks and benefits and adverse effects of the medication.
Morning Re-evaluation Day 3
Upon psych re-evaluation the patient is AOx3, cooperative with a soft slow speech. She is not tearful and states she realizes that her family situation is causing her to feel depressed. She states she has taken upon too many responsibilities and will tell her siblings to help out. She states she “ is upset that I thought of harming myself” and that “I was just overwhelmed”. She spoke with her best friend who she has known since high school who lives in Delaware and is planning to move there. She is helping her find a job prior to her moving. She reports most of her friends are in Delaware and thinks she will be much happier there and will have less responsibilities. Patient recompensated and has improved and has significantly improved control during the CPEP stay. She states she “ is upset that I thought of harming myself” and that “I was just overwhelmed”. Patients behavior was calm and did not require IM medications. Patient had routine work up with no significant findings. Patient was started on remeron 15 mg at bedtime.. Patient tolerated medication without adverse effects. Collateral information was obtained from the patient’s sister. Decision was made to discharge to the community due to pt denying any suicidal ideation,intention or plan. Discharged on mirtazapine (REMERON) 15 MG tablet 1 tablet PO.
Discharge to the community with follow up care. Patient educated about the need for attend follow-up care and the need for medication adherence. Advised to call after discharge to writer with any questions prior to connecting to outpatient care
UA w/ Reflex to Microscopy
| Component | Ref Range & Units | |
| pH Urine | 5.0 – 7.5 | 5.5 |
| Color Urine | Yellow | Yellow |
| Appearance Urine | Clear | Clear |
| Glucose Qualitative Urine | Negative mg/dL | Negative |
| Bilirubin Urine | Negative | Negative |
| Ketones Urine | mg/dL | 80 |
| Specific Gravity Urine | 1.005 – 1.030 | 1.026 |
| Blood Urine | Negative | Negative |
| Protein Urine | Negative mg/dL | 30 Abnormal |
| Urobilinogen Urine | 0.2 – 1.0 mg/dL | 1.0 |
| Nitrite Urine | Negative | Negative |
| Leukocyte Esterase Urine | Negative | Negative |
| White Blood Cells Urine | 0 – 4 HPF | 0-4 |
| Red Blood Cells Urine | 0 – 3 HPF | 4-6 Abnormal |
| Bacteria Urine | Negative | Negative |
| Squamous Epithelial Cells Urine | 0 – 4 HPF | 0-4 |
| Hyaline Cast Urine | 0 – 4 /lpf | 0-4 |
Drug Screen Qual 5 Panel, Urine
| Barbiturates QUAL Urine | Negative ng/mL | Negative |
| Benzodiazepines QUAL Urine | Negative ng/mL | Negative |
| Cocaine Qual Urine | Negative ng/mL | Negative |
| Methadone Qual Urine | Negative ng/mL | Negative |
| Opiates Urine | Negative ng/mL | Negative |
| Creat, Urine (DAU) | 20.0 – 250.0 mg/dL | 69.9 |
| THC Urine | Negative ng/mL | Negative |
| Amphetamines | Negative ng/mL | Negative |
| Phencyclidine Urine | Negative ng/mL | Negative |
CBC
| Component | Ref Range & Units | |
| WBC | 4.80 – 10.80 x10(3)/mcL | 4.45 Low |
| RBC | 4.20 – 5.40 x10(6)/mcL | 4.80 |
| HGB | 12.0 – 16.0 g/dL | 14.8 |
| HCT | 37.0 – 47.0 % | 44.7 |
| MCV | 80.0 – 99.0 fL | 93.1 |
| MCH | 27.0 – 31.0 pg | 30.8 |
| MCHC | 29.8 – 35.2 g/dL | 33.1 |
| MPV | 8.7 – 12.9 fL | 8.3 Low |
| RDW | 12.0 – 15.0 % | 11.9 Low |
| PLT | 150 – 450 x10(3)/mcL | 281 |
| Neutrophil % | 44.0 – 70.0 % | 37.6 Low |
| Lymphocyte % | 20.0 – 45.0 % | 51.0 High |
| Monocyte % | 2.0 – 10.0 % | 10.1 High |
| Eosinophil % | 1.0 – 4.0 % | 0.9 Low |
| Basophil % | 0.0 – 2.0 % | 0.4 |
| Imm Gran % | 0.0 – 2.0 % | 0.0 |
| Neutrophil Abs | 2.10 – 7.60 x10(3)/mcL | 1.67 Low |
| Lymphocyte Abs | 1.00 – 4.90 x10(3)/mcL | 2.27 |
| Monocyte Abs | 0.10 – 1.10 x10(3)/mcL | 0.45 |
| Eosinophil Abs | 0.10 – 0.40 x10(3)/mcL | 0.04 Low |
| Basophil Abs | 0.00 – 0.20 x10(3)/mcL | 0.02 |
| Immature Gran Abs | 0.00 – 0.20 x10(3)/mcL | 0.00 |
| NRBC Abs | <=0.00 x10(3)/mcL | 0.00 |
| NRBC % | 0.0 – 0.0 % | 0.0 |
| Component | Ref Range & Units | 4/17/22 0725 |
| Indices | Slight Hemolysis. Slight Icteris. | |
| Sodium | 136 – 145 mmol/L | 138 |
| Potassium | 3.5 – 5.1 mmoL/L | 4.4 |
| Chloride | 98 – 108 mmol/L | 102 |
| CO2 | 22 – 29 mmol/L | 22 |
| BUN | 6 – 23 mg/dL | 10 |
| Creatinine | 0.50 – 1.20 mg/dL | 0.86 |
| Glucose | 74 – 110 mg/dL | 89 |
| Calcium | 8.6 – 10.3 mg/dL | 9.9 |
| Anion Gap | 8 – 16 mEq/L | 14 |
| Albumin | 3.5 – 5.2 g/dL | 4.7 |
| Total Protein | 6.6 – 8.7 g/dL | 7.2 |
| Total Bilirubin | 0.0 – 1.2 mg/dL | 1.0 |
| ALK PHOS | 35 – 104 U/L | 66 |
| ALT (SGPT) | 0 – 33 U/L | 9 |
| AST (SGOT) | 5 – 32 U/L | 15 |
| eGFR(cr) | >=60 ml/min/1.73m2 | >60 |
Blood Alcohol Level
| Component | Ref Range & Units | |
| Alcohol | <=50 mg/dL | <10 |
Magnesium
| Component | Ref Range & Units | |
| Magnesium | 1.60 – 2.60 mg/dL | 2.20 |
HCG
| Component | Ref Range & Units | |
| HCG Quant | <=5.0 mIU/mL | 2.8 |
Acetaminophen
| Component | Ref Range & Units | |
| Acetaminophen | 10 – 30 ug/mL | <5 Low |
Salicylate
| Component | Ref Range & Units | |
| Salicylate | 3.0 – 30.0 mg/dL | <0.4 Low |
