Name: CM
DOB: xx/xx/1957
Race: Asian, Chinese American
Sex: female
Date: April 20, 2021
Time: 12:00pm
Source of information: Self, brother
Reliability: reliable
Location: QHC CPEP
Mode of transport: EMS
Referral: brother
Chief Complaint: “My brother’s wife has a copy of my house and she is breaking in stealing my knives and clothes.”
64 year old female Chinese female, Mandarin speaking, single, domiciled alone with a prior psych history of mental illness status post MVA in 2014s, no known medical history, no known substance abuse history, brought in by EMS activated by brother (###-###-####) secondary to paranoid and aggressive behavior. Patient evaluated in the medical ER, noted to be calm, superficially cooperative and minimizing symptoms. She states she was missing a knife and went to her brothers house to retrieve it and brother called 911. Patient states over the past month she has repeatedly been missing knives and believed brothers wife has been taking them. She states his brother is a construction worker and his wife created a copy of her house key and that she comes into her house when she is not there and steals her knives and clothes. She states she has “no underwear left”. Patient denies making any threats towards brother or family. Patient currently denies any thoughts of self harm or harming others. Denies perceptual disturbances. Patient is alert and oriented x3. However, continues to be a poor historian with minimal insight into her mental health. Patient does admit that she was hospitalized in Jamaica Hospital for 2 to 3 weeks in the past and was treated with medications. She does not recall the name of the medication and admits to poor compliance with treatment. Denies any suicidal or homicidal ideation or auditory or visual hallucinations.
Writer spoke to a brother who reports, patient has been increasingly paranoid and aggressive in recent times. He states over the past 1 week she has come to his house repeatedly banging on the door and being aggressive. Reports last night at 2:30am patient broke his door knob and was waving a butcher knife. Mother reports the patient has not been taking her medications after being discharged from jamaica hospital 3 months ago and that patient was admissited for 3 weeks for similar behavior. Mother unable to provide information regarding medication or diagnosis.
Patient was cleared by MER and transferred to CPEP. Upon psychiatry evaluation in CPEP triage, patient remains AAOx3, superficially cooperative, poor historian with minimal insight into her mental health.
Patient was re-evaluated in CPEP today and continues to be disorganized, paranoid and delusional after taking Risperdal 1mg x2 while in EOU. She remains labile and unstable and was also started on Depakote 250mg x3. Patient was admitted with EOU with no improvement of mental status and remains delusional.
Patient denies any act suicidal or homicidal ideation and audiotyr or visual hallucatioms but is noted to be internall pre-ouccpied at times and pacing in the hallways and very anxious and unrpedictable. Patient with limited insight into her mental status and continues to present with impaired judgment and impulse control and poor insight. While in CPEP patients did not require STAT oral, IM medications and restraints. Patient had routine work up with no significant findings. Patient was started on Risperidone 1mg PO BID. Patient tolerated medication without adverse effects. Brother reports the patient has not been taking her medications after being discharged from Jamaica Hospital 3 months ago and has decompensated. Brother states the patient was admitted to Jamaica Hospital for similar behavior for 3 weeks/ Patient presentation was felt to be related to psychosis and delusional beliefs and paranoia and is a possible danger to self and others. After evaluation and observation the decision was made to admit to IP as she did not improve with treatment in CPEP and EOU and will be admitted to P5 as she meets criteria under 9/27 mental hygiene law due to continued decompensation.
PMHx: unknown mental illness status post MVA in 2014, Pt denies childhood illness. Immunizations are up to date (including COVID vaccine). No booster.
PSHx: denies
Medications
Denies
Allergies
Denies
Family History
Mom – deceased at 85, Alzehemiers
Dad – deceased at 87, HLD
Grandparents – pt is unable to recall
Social History
- Patient is living in an apartment
- She works at a nail salon
- She has no children, is not married
- She is not currently sexually active, denies h/o STIs
- No recent travel
- She does not drunk alcohol or uses any other substance
- She does not exercise
- Sleep 7 to 8 hours every night
- She cooks her meals at home and does not eat fast food
General – No recent weight loss or gain, loss of appetite, weakness/fatigue, fever or chills, night sweats
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, palpitations, irregular heartbeat, edema, syncope, known heart murmur
Psychiatric
No sign of depression, suicidal ideation, anxiety, obsessive/compulsive disorder.
Physical Exam:
Vital Signs
o BP 135/82 mmHg sitting
o Pulse 76 bpm regular
o Temperature 36.7 °C
o Respiratory rate 14 unlabored
o O2 Sat 98% on room air
o Height: 65”
o Weight: 154 lbs
o BMI = 25.2
Mental Status Exam
General
• Appearance – CM is an average Asian American with short hair who appears well groomed. She is dressed in appropriate attire and appears well nourished with good hygiene. She appears her stated age with no trauma or and has slight facial flushing.
• Behavior and psychomotor activity – Upon evaluation the patient is confused, labile and keeps talking about her knives. Patient is able to sit still during interview and has appropriate gait and posture.
• Attitude towards Examiner – patient is calm, cooperative with verbal questioning and often rambles. Patient becomes hyperverbal when the discussion is about her sister in law.
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 interview but would go on tangents about her brother and his wife and did not maintain eye contact.
- Capacity to read and write – average reading and writing ability displayed upon signing of admission documents
- Abstract Thinking – limited
- Memory – Recent memory intact as she was able to include ages, dates, but remote memory is impaired. Her timeline of events is disorganized and is recalling incorrect information.
- Fund of information and knowledge – Pts intellectual performance was average and consistent with her level of education
Mood Affect
• Mood – labile mood, irritable and angry when she describes her brother and his wife and how they are stealing items.
• Affect –blunted
- Appropriateness – mood and affect were congruent throughout the interview
Motor
• Speech – D.H.’s rate of speech was quicker than average with normal rhythm. Her volume of speech was high at times and slightly slurred.
• Eye Contact – Pt maintained good eye contact throughout interview but would occasionally look around. Eyes appeared teary with slightly droopy eyelids.
• Body Movements – fluid motor movement. No tics or unintentional body movements.
Reasoning and Control
• Impulse control – patient displays adequate impulse control with no suicidal or homicidal urges.
• Judgement – Pt is paranoid that others are talking about her and has delusions about her upstairs tenants following and mocking her. She is convinced that is has the ability to hear from far distances and does not consider the voices hallucinations.
• Insight – Pt has poor insight as she is unable to differentiate between reality and her hallucinations. She does not believe she needs treatment and requests to return back home.
Patient sex assigned at birth: female
Mental Status Exam
Appearance: poor eye contact
Behavior: restless, appears to be responding to internal stimuli
Attention: Alert
Attitude: superficially cooperative
Speech: Normal
Mood: euthymic
Thought content: paranoid ideas (non-delusional)
Suicidal ideation: none
Homicidal ideation: none
Insight- 1- moderate
Judgment: impaired
Impulse control: impaired
Diagnosis
- Psychosis- unspecified psychosis type
- Substance Induced Psychosis – urine toxicology was positive for cannabis and alcohol intoxication and symptoms have appeared on and off this past week possibly in alignment with when she used the substances
- Brief psychotic disorder – though the duration of symptoms qualifies (greater than one day but less than a month), symptoms cannot be attributable to substance use which appears to be the case. This diagnosis should be reconsidered if patient continues to experience hallucinations after stabilization and substance withdrawal.
- Schizophreniform – though auditory hallucinations and delusion is present, symptoms have not lasted greater than one month
- Schizophrenia – though auditory hallucinations and delusion are present, symptoms have not lasted greater than 6 months
- Schizoaffective disorder – Delusions and hallucinations have not been present for at least two weeks. There is also no indication of mood disorder present and this diagnosis requires that symptoms are not attributable to substance abuse
- Neurological disorders
- Alzheimer’s or Lewy Body Dementia – However, visual hallucinations are much more common. In addition, patient is alert and oriented x 3, has fairly good memory, and functional abilities
Labs/Imaging Results
CBC
| Component | Ref Range & Units | |
| WBC | 4.80 – 10.80 x10(3)/mcL | 7.61 |
| RBC | 4.20 – 5.40 x10(6)/mcL | 4.36 |
| HGB | 12.0 – 16.0 g/dL | 13.6 |
| HCT | 37.0 – 47.0 % | 42.5 |
| MCV | 80.0 – 99.0 fL | 97.5 |
| MCH | 27.0 – 31.0 pg | 31.2 High |
| MCHC | 29.8 – 35.2 g/dL | 32.0 |
| MPV | 8.7 – 12.9 fL | 10.2 |
| RDW | 12.0 – 15.0 % | 12.2 |
| PLT | 150 – 450 x10(3)/mcL | 233 |
| Neutrophil % | 44.0 – 70.0 % | 70.6 High |
| Lymphocyte % | 20.0 – 45.0 % | 19.8 Low |
| Monocyte % | 2.0 – 10.0 % | 7.8 |
| Eosinophil % | 1.0 – 4.0 % | 0.8 Low |
| Basophil % | 0.0 – 2.0 % | 0.7 |
| Imm Gran % | 0.0 – 2.0 % | 0.3 |
| Neutrophil Abs | 2.10 – 7.60 x10(3)/mcL | 5.38 |
| Lymphocyte Abs | 1.00 – 4.90 x10(3)/mcL | 1.51 |
| Monocyte Abs | 0.10 – 1.10 x10(3)/mcL | 0.59 |
| Eosinophil Abs | 0.10 – 0.40 x10(3)/mcL | 0.06 Low |
| Basophil Abs | 0.00 – 0.20 x10(3)/mcL | 0.05 |
| Immature Gran Abs | 0.00 – 0.20 x10(3)/mcL | 0.02 |
| NRBC Abs | <=0.00 x10(3)/mcL | 0.00 |
| NRBC % | 0.0 – 0.0 % | 0.0 |
BMP
| Component | Ref Range & Units | |
| Sodium | 136 – 145 mmol/L | 141 |
| Potassium | 3.5 – 5.1 mmoL/L | 4.8 |
| Chloride | 98 – 108 mmol/L | 105 |
| CO2 | 22 – 29 mmol/L | 27 |
| BUN | 6 – 23 mg/dL | 24 High |
| Creatinine | 0.50 – 1.20 mg/dL | 0.56 |
| Glucose | 74 – 110 mg/dL | 99 |
| Calcium | 8.6 – 10.3 mg/dL | 9.8 |
| Anion Gap | 8 – 16 mEq/L | 9 |
| eGFR(cr) | >=60 ml/min/1.73m2 | >60 |
COVID → Negative/ Not detected
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 |
Plan
Admit to CPEP for further psychiatric evaluation, observation and stabilization
Follow up with collared for evaluation of patients baselines functioning and additional history
Reconcile medication and restart home medications as appropriate.
Patient started on Risperidone 1mg twice per day. Consider STAT medications for stabilization.
Follow up urine tox to reule out drug indeice presentation
Review lab results
Re-evaluate patient in the morning for further disposition
Maintain observation and safety
