Identifying Information:

Name: MG

Sex: Female

DOB: 3/21/1989

Date: 6/30/21, 10:30 AM

Location: Elmhurst Hospital Center, Inpatient Psychiatry AB11

Source of Information: Self

Source of Referral: brought in by EMS, self-activated due to paranoid behavior

Mode of Transportation: ambulance

Chief Complaint: “my roommate is out to get me” 

History of Present Illness:

MG is a 32 y/o English speaking Caucasian female, single, with 13 year old child in custody of father (per roommate there is a restraining order against patient), unemployed, domiciled with roommate, with no PMH, PPH of Schizophrenia, prior CPEP visits, 3 prior inpatient admissions per chart review (2011, 2019 in Colorado, most recently AB11 9/15/2020-10/1/2020 for similar presentation- decompensation in the setting of medication non-compliance), no history of suicide attempts/ self-injurious behaviors, homicidal behavior. She is not currently followed by an outpatient provider and has history of medication and treatment non-compliance.

Upon interview in CPEP, she reported she called EMS because “the man in my apartment is abusive and told me to kill myself”. On assessment, she was calm, superficially cooperative, irritable, illogical, tangential, noticeably paranoid, with poor insight, guarded, condescending, and grandiose, noted to be internally preoccupied. Patient stated “I will only answer questions if they are peaceful.” Patient states that today she was watching news about a building collapse in florida and the roommate unplugged the TV for unknown reasons. Patient became irritable with questioning, stating “I am in an interrogation room. I do not know what else you would call it.”, and responded to questions about alcohol/drug abuse with “I am going to choose not to answer that for personal reasons.” Patient reported feeling irritated that “the subject is being changed” and states she wants to talks about the reason she was brought here, however, was unable to state how the hospital can help. Patient denied suicidal/homicidal ideations, auditory/visual hallucinations.

Patient was admitted to inpatient psychiatry unit AB11 for further monitoring and stabilization.On assessment, patient appears stated age, disheveled, wearing hospital clothing. Patient presents with fair eye contact, paranoid, guarded, condescending, oppositional, and grandiose, with poor insight. Patient was noted to be superficially cooperative, engaging in excessive, dramatic body movement (ie: eye rolling, turning her body fully toward/ turning her back to treatment team members.) Speech was mildly pressured and mostly illogical and loosely associated. On interview, she reported that she was admitted due to a “violent abusive man.” She offered clarification that treatment questions were about her and should be focused on the man who is abusive toward her, and provided his name (CM). She directed the treatment team to her chart stating that she has answered all these questions and would not repeat herself and refused to answer most questions. She endorsed paranoia, stating that she believes all people representing psychiatry are fake, and reported feeling targetted in the community. She also reported that all of her problems would go away if she had a secure place to live, stating “all I need is that you give me keys to an apartment and everything will be okay.” She refused to answer questions about substance use, suicidal ideation, behavior, suicide attempt, or legal history. Following interview, she was observed talking to herself while pacing the hallway. 

  Collateral information was obtained by patient’s roomate, who stated that he began caring for the patient last year after she was squatting in different people’s houses, and he felt bad for her so he took her in. He reports that the patient has been off medications for around 6 months and has been decompensating. He reports the patient is very argumentative, difficult, grandiose, and not at baseline. He states today while the patient was watching TV his mother called, and she kept making the TV louder and louder so he unplugged it, so the patient called 911, and he called 911 to let them know about the patient’s declining mental health. 

Past Psychiatric History: Schizophrenia- noncompliant with medication, patient currently has symptoms of paranoia, delusions,  illogical speech

Past Medical History: patient denies

Past Surgical History: patient denies

Medications: patient denies taking medications

Allergies: Patient denies any food, drug, or environmental allergies

Trauma history: Patient states she was emotionally abused by roommate, states she “is not sure” if she ever faced physical or sexual abuse, no known history of trauma

Family history: Patient was born in Virginia, to 2 parents and 1 older sibling. Patient was raised by birth parents, with no history of foster care. Patient has a 13 y/o son in custody of his father, living in Texas, as per roommate, there is a restraining order against patient. Patient denies any family history of medical or psychiatric conditions, history of physical or sexual abuse by family members.

Social and Occupational history: MG is a 32 year old single Caucasian male, unemployed (last worked as staff for Public Policy school in Texas 16 months ago), domiciled in apartment with roommate. Highest education is college degree. Patient has no source of income. She has a history of prior CPEP visits and multiple hospitalizations (3 prior inpatient admissions per chart review-2011, 2019 in Colorado, most recently AB11 9/15/2020-10/1/2020 for similar presentation- decompensation in the setting of medication non-compliance). She denies having any current social support. She denies smoking, alcohol use, or illicit substance use, and refuses urine drug screen. Patient states she has not been sleeping well recently, and only sleeps for about 3 hours per night.

Review of Systems:

General: Patient denies any fever, chills, loss of energy/ fatigue, unintentional weight loss or gain, changes in appetite.

Skin: patient denies pruritus, discoloration, rashes, lesions, masses or scarring.

Musculoskeletal: denies any back pain, joint pain, stiffness, or joint swelling.

Neurologic: patient denies headaches, loss of consciousness, history of head trauma or

injury, unsteady gait, seizures.

Psychiatric: patient denies current suicidal ideation, plan, or intent. She denies homicidal

ideation, plan, or intent and denies auditory or visual hallucinations.

Vital Signs:

Blood pressure: 105/62 (right arm, sitting)

Pulse: 109 bpm, regular

RR: 18 breaths per minute, regular, unlabored

Temperature: 98.2 F, oral

Oxygen saturation: 99% on room air

Height: 5’6”

Weight: 162 lbs

BMI: 26.2

Physical Exam:

General: alert and oriented to person, place and time. Disheveled, wearing hospital clothing, agitated and superficially cooperative. Appears stated age, sitting back in chair.

Skin: No masses, lesions, rashes or excoriations. No evidence of intravenous drug use, skin picking or self-inflicted wounds. No excessive sweating or dryness noted.

Patient refused further physical exam

Mental Status Exam:

General

Appearance: MG is a medium build Caucasian female wearing hospital pajamas. She appears her stated age, casually groomed with good hygiene. Dramatic eye contact. No obvious scars or injuries. 

Behavior: prior to the interview MG was walking around the halls. In the interview she was sitting up in her chair, with dramatic body movement and gestures. She does not appear to have any tics, tremors or psychomotor retardation.

Attitude toward examiner: guarded, superficially cooperative, hostile at times 

Sensorium and cognition:

Alertness and consciousness: patient is alert with a stable level of consciousness

throughout entire interview

Orientation: patient oriented to person, place, and time.

Concentration and attention: MG demonstrated impaired concentration and attention, she was unwilling to answer questions and had difficulty staying focused throughout the interview.

Visuospatial ability: MG had good visual perception with appropriate balance,

normal gait and purposeful body movements as observed as she walked around

the unit and entered and exited the interview room.

Capacity to read and write: average reading and writing capability as demonstrated by her ability to read and sign forms.

Abstract thinking: MG demonstrated fair abstract thinking by understanding commonly used English metaphors.

Memory: MG demonstrated unimpaired memory as she was able to describe the events leading up to her hospitalization.

Fund of information and knowledge: intellectual performance was average and consistent with education level.

Mood and Affect:

Mood: irritable, labile

Affect: reactive

Appropriateness: MG’s mood and affect were incongruent and inappropriate to the

topics she was speaking about. However, she did not exhibit emotional lability, uncontrolled anger or uncontrollable crying.

Motor:

Speech: Mildly pressured, tangential, and circumstantial

Eye contact: Maintained appropriate eye contact while speaking and listening.

Body movements: Overexxagerated, dramatic body movement and gestures. No tics or tremors

noted. Gait was observed on the unit and was normal. She remained seated throughout the exam.

Reasoning and Control:

Thought pattern/process: Circumstantial, illogical, perseverative 

Thought content: Grandiosity, Paranoid ideas, persecutory delusions about psychiatry providers She denied auditory or visual hallucinations.

Impulse control: Impaired- as per roommate, patient kept increasing volume of television as he was speaking to his mother

Judgement: Impaired- thinks psychiatry is a fake profession and everyone is posing

Insight: Minimal insight into psychosocial and psychiatric problems

Assessment: 

MG is a 32 y/o English speaking Caucasian female, single, with 13 year old child in custody of father (per roommate there is a restraining order against patient), unemployed, domiciled with roommate, with no PMH, PPH of Schizophrenia, prior CPEP visits, 3 prior inpatient admissions per chart review. She presented to the ER after calling EMS stating, “the man in my apartment is abusive and told me to kill myself.” Patient presented with fair eye contact, paranoid, guarded, condescending, oppositional, and grandiose, with poor insight. She was noted to be superficially cooperative, engaging in excessive, dramatic body movement, with mildly pressured, illogical, and loosely associated speech. She denied auditory/ visual hallucinations, suicidal/homicidal ideations, intent or plan. She will benefit from medication/ medical stabilization, individual and group daily psychotherapy, and observation.

Differential Diagnoses:

1. Schizophrenia- has history of schizophrenia, not taking medications. Currently presents with illogical speech and delusions/ paranoia that psychiatry is fake and everyone in the psychiatric field is out to get her. 

(Could also be delusional story, but addition of illogical speech and h/o schizophrenia leads more towards schizophrenia)

2. Bipolar 1 Disorder with Mania (Manic Episode)- irritable mood, disorganized, tangential speech, grandiose thoughts, mildly pressured speech, decreased sleep, impaired judgment and impulsiveness. Also has psychotic symptoms including delusions and paranoia (explained above)
3. Schizoaffective Disorder (Bipolar Type)- has symptoms of schizophrenia, such as delusions and illogical speech, as well as symptoms of mania, such as grandiose thoughts, mildly pressured speech, and decreased sleep. 
4. Borderline Personality Disorder- exhibiting impulsivity (made TV louder and louder as roommate was speaking on phone), unstable relationships (no current relationships, called 911 on roommate who is only current social and financial support), has difficulty trusting, irrational fear of other people’s behavior- does not believe psychiatrists actually want to/ will help her, feels targetted by roommate and others in community
5. Paranoid Personality Disorder- extremely distrustful and suspicious of others- believes that psychiatry is fake, everyone claiming to help her is really hurting her, feels targetted in the community .
6. Narcissistic Personality Disorder- grandiose sense of self-importance and superiority, believes that others are the problem, not her, believes she is special and others need to give her keys to her apartment, seemed to lack empathy for roommate who was housing her when made TV louder and louder and then called 911 on him,
7. Histrionic Personality Disorder- overly dramatic in facial expressions, body movement, and speech 

Treatment plan:

1. Medications: 
   1. Risperidone disintegrating tablet 1mg, PO, BID
   2. Haloperidol tablet 5 mg, PO, Q8H PRN
   3. Lorazepam tablet 2 mg, PO, Q8H PRN (1 mg)
2. Individual psychotherapy daily, as well as group therapy 
3. Ensure calm, safe environment on the unit
4. Regular diet
5. Re-evaluate in 24 hours
6. Expected length of stay 7-14 days, discharge plan to shelter with outpatient mental health service
7. Discuss with patient importance of taking medications and following up with outpatient treatment