Identifying Information:

Name: QH

Sex: Male

Race: Asian

Marital Status: Single

DOB: 1/12/1995, 26 years old

Date: 7/13/21, 11:00 AM

Location: Elmhurst Hospital Center, Inpatient Psychiatry AB11

Source of Information: Self

Source of Referral: father called 911 after Pt overdosed on medications

Mode of Transportation: EMS

Chief Complaint: “I took too many pills”

History of Present Illness:

QH is a 26 year old English speaking Chinese male, single, domiciled with family (mother, father, brother- reports poor relationship with brother), and is employed as a paraprofessional (math teacher’s assistant for elementary school children with special needs), but is currently off for the summer. Patient has no PMH, PSH of Bipolar affective disorder (manic depression), Generalized Anxiety Disorder, and Borderline Personality Disorder requiring multiple previous inpatient psychiatric admissions. Last admission was 6/20/2021 in QHC and patient was discharged on 6/30/21 with prescription for Escitalopram 15mg daily, Lamotrigine 25mg daily and Quetiapine 50mg daily. Pt also has past suicide attempt via overdose in 2016 as well as remote history of jumping from 2nd floor of a building leading to left arm fracture. Patient was brought in by EMS on 7/04/21 s/p suicide attempt by OD (Quetiapine 50mg x 20 pills, Escitalopram 5mg x 81 pills, Lamotrigine 25mg x 20 pills).

After discharge from QHC on 6/30/21 patient reported feeling well and was in a good mood until the next morning when he began feeling a “heaviness in the chest,” sadness, and was continuously crying. This continued for 3 days where patient felt progressively more hopeless that condition would not improve, guilty towards the treatment team as he was not improving, and disappointed at the return of the depressive symptoms so soon after discharge. This culminated in the patient impulsively attempting suicide via OD with at home medications. Pt took the medications with intent to die as he could no longer tolerate his daily suffering, however, he denies having plan to commit suicide prior to attempt and admits that he immediately tried to vomit the medications after ingestion, but failed to induce vomiting. Pt then called his father which lead to contacting EMS and being brought to Elmhurst Hospital ED where activated charcoal was administered and he vomited afterwards. Patient was admitted to inpatient medicine and was followed by the clinical team which recommended inpatient psychiatry admission. 

On assessment today, patient was intermittently tearful and expressed feelings of hopelessness regarding his depression, stating that “the medications aren’t working” and asking the team if we could administer a lethal injection during hospitalization. On direct questioning regarding suicidal ideation, the patient stated “I don’t know.” Pt also endorsed feelings of guilt and decreased appetite (requesting ensure supplementation for this), but denied sleep disturbance or decreased energy and continues to find his work interesting, but nothing else is interesting to him or brings him joy. Pt frequently requested transfer to QHC, stating that he prefers his team there and requested to see them. When asked what he required of the team there and if we could provide it, he could not specify what was needed. Pt endorsed multiple episodes of elevated mood that last for one day, one of which was accompanied by an episode of increased sexual arousal resulting in him going on a date with someone he met online, which subsequently resulted in him being constantly concerned that he has contracted HIV (even with negative HIV tests to date.) Pt denies disturbed sleep during these episodes. Pt denies auditory/ visual hallucinations, no homicidal or violent ideation and no history of violence. 

After the interview, patient was seen pacing around the halls and picking at his nails. When staff attempted to redirect him, he began to cry and yelled that the staff are trying to cut off his fingers. He was reassured by the staff, but continued to make these claims. 

Pt is at risk for harming himself in the community in the context of and depressive symptoms and potential suicidal ideation. He requires inpatient level of care to stabilize patient and minimize risk of danger to self or others in the community and for treatment of depressive symptoms with evaluation of progress with medication adjustment and individual psychotherapy. 

Past Psychiatric History: Bipolar affective disorder (manic depression), Generalized Anxiety Disorder, Borderline Personality Disorder

Past Medical History: patient denies

Past Surgical History: patient denies

Medications: 

Quetiapine 50 mg QHS, for psychotic symptoms

Escitalopram 5 mg QD, for depressive symptoms

Lamotrigine 25 mg QD, for Bipolar Disorder

Allergies: Mango- gets nauseous. Patient denies any other food, drug, or environmental allergies

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

Family history: Pt was born in China and moved to NY when he was 6. He was raised by his biological mother and father. He one younger brother, who, as per patient, he does not interact with. He described his upbringing as “good.” Patient denies any family history of medical or psychiatric conditions, history of physical or sexual abuse by family members.

Social and Occupational history: QH is a 26 year old single, English speaking Chinese male, domiciled with family (mother, father, brother), and is employed as a Paraprofessional but is currently off for the summer. His highest level of completed education is a college degree. He has extensive previous history of CPEP visits and multiple hospital admissions, most recently at QHC on 6/20/21, discharged on 6/30/21 . He denied trauma, legal and military history. He denied smoking, alcohol use, or significant history of substance use. Pt states he has been sleeping well, for about 7 hours every night.

Review of Systems:

General: Denies generalized weakness, 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 admits to depression and feelings of hopelessness. Patient is evasive regarding suicidal ideation, plan, or intent. He denies homicidal ideation, plan, or intent and denies auditory or visual hallucinations.

Vital Signs:

Blood pressure: 125/83 (right arm, sitting)

Pulse: 81 bpm, regular

RR: 18 breaths per minute, regular, unlabored

Temperature: 97.5 degrees F, oral

Oxygen saturation: 99% on room air

Height: 5’8”

Weight: 162 lbs

BMI: 24.6 

Physical Exam:

General: alert and oriented to person, place and time. Appears stated age, average build, well-developed and well nourished. 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 sounds, 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.

EKG- Normal Sinus rhythm with QTc of 457 (normal 350-440 mms)

Mental Status Exam:

General

Appearance: QH is a Chinese male, of average build, wearing a T shirt and pants. He appears his stated age, well groomed with good hygiene. No obvious scars or injuries. 

Behavior: Prior to interview was laying in bed. In the interview he was sitting up in his chair and well-focused, but frequently burst into tears. 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: sad/depressed/ hopeless/ anxious

Affect: appropriate

Appropriateness: QH’s mood and affect were congruent and appropriate to the topics he was speaking about. He exhibited emotional lability, with uncontrollable crying multiple times throughout the interview, due to his depressed state and his feelings of hopelessness. He did not exhibit uncontrolled anger.

Motor:

Speech: Normal speech, began yelling at times throughout interview when got very upset

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: Normal thought process

Thought content:Thoughts of worthlessness, hopelessness. Also endorsed grandiosity, stating he needs to be better now and must be transferred to QHC where he will get the best care from the best doctors. He denied auditory or visual hallucinations.

Impulse control: Patient has poor impulse control, overdosed on pills when felt sad, began yelling and crying when got very upset during interview

Judgement: Patient has good judgment- understood that the medications he had taken could kill him and quickly called for help

Insight: Fair insight into his mental illness, psychosocial and psychiatric problems- stated he was told previously that he has borderline personality disorder and expressed understanding of symptoms related to illness.

Assessment: 

QH is a 26 year old single, English speaking Chinese male, domiciled with family (mother, father, brother), and is employed as a Paraprofessional but is currently off for the summer, with no PMH, PPH of BPAD, GAD, BPD requiring multiple previous inpatient psychiatry admissions, most recently 6/20/21 at QHC, and patient was discharge on 6/30/21. Patient was BIBEMS on 7/04/21 s/p suicide attempt by OD.

After being medically stabilized, patient was admitted to AB11 for continued treatment and further psychiatric stabilization. On assessment, patient reports depressed mood and hopelessness stemming from his current emotional state- persistent low mood. Pt is noted to be evasive when asked about suicidality, but endorses wishes of death (requested lethal injection from treatment team). He presents tearful, and with limited insight, judgment, and impulse control. His presentation currently is in the setting of poor interpersonal engagement following discharge from QHC and possible incomplete resolution of mood symptoms during hospitalization.

At admission, pt is an elevated risk of harm to himself in the community due to SI and depressive symptoms. On unit, risk for harming self is low due to monitoring and environmental safety. He denied auditory/ visual hallucinations, homicidal ideations, intent or plan. Pt will benefit from medication management, psychotherapy, and further evaluation and observation.

Differential Diagnosis

1. Borderline Personality Disorder-swings from extreme closeness and love to extreme dislike or anger (loves the providers at QHC and hates the providers at Elmhurst), cuts off communication with people- has no relationship with his brother, impulsive behaviors- swallowed all the pills in his bottles due to feeling of sadness, had sex with a girl he met online, has recurring thoughts of suicidal behaviors, intense and highly changable moods and emotions, trouble controlling anger, feelings of dissociation from himself, feelings of emptiness and sadness, difficulty trusting others- hesitant to trust treatment team at Elmhurst because does not trust their intentions
2. Major Depressive Disorder- patient feels very sad, hopeless, helpless, does not want to be alive, does not see any way out of his situation 
3. Bipolar Affective Disorder- patient currently appears depressed- sad, helpless, hopeless, but endorses periods where he had elevated mood x 1 day, one period where he had increased sexual arousal and going out with a girl he met online.
4. Bipolar Disorder with Psychosis- patient has periods of depressed mood (currently) as well as periods of elevated mood. He also endorsed some psychotic symptoms, including delusions that staff were trying to cut off his fingers
5. Generalized Anxiety Disorder- patient is constantly worried about his symptoms of helplessness and hopelessness and the fact that he is not getting better. 
6. Illness Anxiety Disorder- endorsed having fears about having contracted HIV after going on a date with a girl he met online, though his tests came back negative.
7. Paranoid Personality Disorder- Patient was angry and hostile towards staff and endorsed feelings of distrust that staff here could help him.
8. Histrionic Personality Disorder- spoke very dramatically, had rapidly changing emotions, felt a very close relationship with team from QHC (though that may not have been the case). However, he did not have a dramatic physical appearance or behave in sexual or seductive ways. 

Treatment plan:

1. Medications: 

1. Escitalopram (Lexapro) 10 mg QD, for depressive symptoms
2. Clonazepam (Klonopin) 1 mg twice daily, for anxiety, impulsiveness, 
3. Quetiapine (Seroquel) 25 mg QD, for psychotic symptoms

2) Individual psychotherapy daily, as well as group therapy 

3) 1:1 Observation due to impulsivity 

4) Encourage compliance with medications and participation in group activities

5) Ensure calm, safe environment on the unit- reinforce behavioral control, personal boundaries, verbalizing feelings in calm way

6) Regular diet

7) Expected length of stay 7-14 days, discharge plan to home with outpatient mental health service