Identifying Information:

Name: JR

Sex: Male

Race: Hispanic

Marital Status: Single

DOB: 3/24/1995, 26 years old

Date: 7/09/21, 11:30 AM

Location: Elmhurst Hospital Center, Inpatient Psychiatry AB11

Source of Information: Self

Source of Referral: came in with mother due to SI and depression

Mode of Transportation: car

Chief Complaint: “I have weakness and muscle tics”

History of Present Illness:

JR is a 26 y.o Hispanic obese single male, domiciled with parents, unemployed, with no PMH, PPH of anxiety, depression, ADHD, and restless leg syndrome, currently connected with a private psychiatrist (since 2 weeks before admission), no known past psychiatric admissions, no past CPEP visits, no known history of violence of aggressive behavior, two previous suicide attempts by attempting to jump off a train but self aborted (3 years ago and 7/07/21), no history of aggressive behavior, who walked into CPEP accompanied by his mother due to patient having SI and depression. Pt was admitted to AB11 for continued treatment and further psychiatric stabilization. 

Today, patient met with treatment team on AB-11, inpatient psychiatry, for evaluation. He reported anxious mood but presented in a calm, well-controlled manner. His speech was clear, coherent, and of normal pace and volume. His thought processes were primarily linear and goal-directed; however, at times perseverative on hypochondriac content. He was open and forthcoming regarding his psychiatric and psychosocial histories. Pt reported on July 7th he was walking when he experienced intrusive thoughts of “this is ultimately going to kill me.” When further clarifying “this,” patient stated that he felt he had undiagnosed ALS. As a result, pt stated he went to the train station with plans to jump in front of an oncoming train. He stated the only thing that saved his life was hearing his mother crying on the phone when he called her prior to attempting. Pt described his plan as impulsive vs premeditated. He reported that on May 24th 2021, he began experiencing hand pain, nerve pain, muscle twitching and weakness. He added that he googled his symptoms and the results showed a possible diagnosis of ALS. Pt explained that since this onset he has received numerous medical evaluations that have all come back negative for any significant medical conditions. Despite this, pt stated “I am still 90% sure I have it.”  Pt endorsed a history of anxiety characterized by worry, nervousness, tenseness, irritability, and fear of failure in relation to his future (mostly regarding employment and financial security having only completed high school.) Pt stated “I wake up scared in the morning.” Secondary to somatic symptoms, pt endorsed depressive symptoms as well, including depressed mood, anhedonia, fatigue, poor focus, lack of motivation, irritability, poor appetite with recent weight loss of 8 pounds, poor sleep (up to 3 days leading to admission), helplessness, hopelessness and suicidality. He denied history of inpatient or outpatient psychiatric treatment. Pt denied suicidality at time of interview. No signs of symptoms of psychosis or mania were observed or reported at the time of the interview, denied auditory/visual hallucinations, delusions.

Pt is at risk for harming himself in the community in the context of anxiety, worsening depressive symptoms and chronic pain. He requires inpatient level of care to minimize risk of danger to self or others in the community and for treatment of anxiety and depressive symptoms with evaluation of progress with medication adjustment and individual psychotherapy. 

Past Psychiatric History: Anxiety, depression, ADHD, restless leg syndrome

Past Medical History: patient denies

Past Surgical History: patient denies

Medications: 

Buspirone (Buspar) 5 mg PO BID, for anxiety

Escitalopram (Lexapro) 5 mg PO, Daily, for depression 

Lorazepam (Ativan) 2 mg,PO, Q6H PRN 

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

Trauma history: Patient denies history of physical, sexual or emotional abuse or trauma

Family history: Pt was born in NY and raised by his biological mother and father. He has 3 older siblings. He described his upbringing as “good.” Pt stated he and his family moved to Arizona in 2011 and returned back to NY following his grandmother’s death 3 years ago. Patient denies any family history of medical or psychiatric conditions, history of physical or sexual abuse by family members.

Social and Occupational history: JR is a 26 year old single, obese Hispanic male, domiciled with parents. He is currently unemployed, has no source of income, and is supported financially by savings and parents. Pt mentioned he was supposed to start a new job on Monday. His highest level of completed education is high school degree. He has no history of CPEP visits or prior psychiatric admissions. He denied trauma, legal and military history. He denied smoking, alcohol use, or significant history of substance use, endorsed recent onset of CBD use approximately 2 weeks ago for pain. Pt states he has not been sleeping well for the past few nights due to anxiety, and only slept for 2-3 hours each night for the past 3 nights. 

Review of Systems:

General: Patient admits to generalized muscle weakness. 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 admits to tingles in feet, uncontrolled muscle ticks. Patient denies headaches, loss of consciousness, history of head trauma or injury, unsteady gait, seizures.

Psychiatric: Patient admits to anxiety, depression, and feelings of hopelessness. Patient denies current suicidal ideation, plan, or intent. He denies homicidal ideation, plan, or intent and denies auditory or visual hallucinations.

Vital Signs:

Blood pressure: 131/89(right arm, sitting)

Pulse: 69 bpm, regular

RR: 18 breaths per minute, regular, unlabored

Temperature: 97.9 degrees F, oral

Oxygen saturation: 99% on room air

Height: 6’0”

Weight: 318 lbs

BMI: 42.2 (obese)

Physical Exam:

General: alert and oriented to person, place and time. Appears stated age, well-deveoped and well nourished, obese body habitus. No acute distress, 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.

Pulmonary/Chest: Normal breathing effort and breaths ounds, no stridor, respiratory distress, wheezing, rales, tenderness.

Abdominal: abdomen soft and non-tender to palpation, no rebound/guarding, BS normal, no distension/ mass

Musculoskeletal: Normal ROM, no edema, tenderness, deformity

Neurological: No CN deficit, exhibits normal muscle tone, coordination, strength 5/5/ throughout. No signs of facial drooping. Speech intact.

Mental Status Exam:

General

Appearance: JR is an obese Hispanic male, wearing a sweatshirt and pants. He appears his stated age, well groomed with good hygiene. No obvious scars or injuries. 

Behavior: within normal limits. Prior to interview was laying in bed. In the interview he was sitting up in his chair and well-focused. He does not appear to have any tics, tremors or psychomotor retardation.

Attitude toward examiner: Cooperative, answered questions as asked and was open and honest with examiners 

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: Good concentration and attention, he was able to stay focused throughout the interview and answered questions properly

Visuospatial ability: Good visual perception with appropriate balance,

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

the unit and entered and exited the interview room.

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

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

Memory: unimpaired memory- was able to accurately describe the events leading up to his hospitalization.

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

Mood and Affect:

Mood: anxious

Affect: appropriate

Appropriateness: JR’s mood and affect were congruent and appropriate to the topics he was speaking about. He did not exhibit emotional lability, uncontrolled anger or uncontrollable crying.

Motor:

Speech: Normal speech, low volume at times but corrected upon request

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

Body movements: Regular body movements. No tics or tremors noted. Gait was observed on the unit and was normal. He remained seated throughout the exam.

Reasoning and Control:

Thought pattern/process: Perseverative on thoughts of having ALS, somatically preoccupied

Thought content: Significant hypochondriasis. He denied auditory or visual hallucinations.

Impulse control: Patient has good impulse control

Judgement: Patient has good judgment- understood he should not jump in front of the train adn should come to the hospital to get help

Insight: Fair insight into his mental illness, psychosocial and psychiatric problems

Assessment: 

JR is a 26 year old Obese, English-speaking Hispanic male, domiciled with mother, unemployed, with no PMH, PPH of anxiety, depression, ADHD, and restless leg syndrome, currently connected with private psychiatrist, no known psychiatric admissions, no past CPEP visits, no known history of violence/aggressive behavior, two previous SA by attempting to jump off a train but self-aborted (3 years ago and on 7/07/21), who walked into CPEP accompanied by mother due to SI and depression. Pt was admitted to unit AB11 for continued treatment and further psychiatric stabilization. At admission, pt is an elevated risk of harm to himself in the community due to SI and plan, history of aborted attempts, chronic pain, and worsening depressive symptoms. On unit, risk for harming self is low due to monitoring and environmental safety. He denied auditory/ visual hallucinations, suicidal/homicidal ideations, intent or plan. Pt will benefit from medication management, psychotherapy, and further evaluation and observation.

Differential Diagnoses:

1. Major Depressive Disorder-sad mood, feelings of helplessness and hopelessness, endorses changes in sleep (does not sleep well), lower energy level, concentration, behavior, and self-esteem (feels that he cannot successfully hold a job), came in following suicide attempt due to these feelings.
2. Generalized Anxiety Disorder- constant worry, restlessness, and trouble concentrating. Feels worried about working, worried about having ALS, worried about life in general.
3. Illness Anxiety Disorder- has hypochondriasis- intense fear/worry/ belief of having ALS, due to minor symptoms such as nerve pain and muscle twitching, despite all lab tests being negative for ALS
4. Conversion Disorder/ Functional Neurologic Symptom Disorder-has neurologic symptoms- nerve pain, muscle twitching, etc that cannot be explained by any tests- not positive for any neurologic disorders upon testing.
5. Somatic Symptom Disorder- has a significant focus on his medical symptoms which is causing him major distress and interrupting his functioning, to the extent that he almost committed suicide. He has excessive anxious thoughts and negative feelings regarding his physical symptoms. However, these physical symptoms are not involving multiple body systems, and are most neurological. 
6. Obsessive Compulsive Disorder- has obsessive and unreasonable thoughts and fears about having ALS, despite all lab tests being negative, but does not really have compulsions associated with it. 

Treatment plan:

1. Medications: 
   1. Levetiracetam, 250 mg, PO Q12H (for anxiety/depression)
   2. Mirtazapine, 15 mg, PO, nightly (for sleep)
   3. Trazodone, 50 mg, PO, nightly  (for sleep)
2. Individual psychotherapy daily, as well as group therapy 
3. Relaxation exercises daily
4. Obsessive Compulsive Scale to evaluate for OCD
5. Ensure calm, safe environment on the unit
6. Regular diet, promote healthy eating habits, meet calorie and protein needs
7. Re-evaluate in 24 hours
8. Expected length of stay 7-14 days, discharge plan to home with outpatient mental health service
9. Discuss with patient importance of taking medications and following up with outpatient treatment 
10. Obesity- encourage life style modification such as light exercise and basic portion diet, eat moderately and avoid overeating