For my Psychiatry rotation, I had the pleasure of meeting Dr. Saint Martin, the medical director for our program, to whom I was able to present some of the interesting cases I came across during my time there. Of the two cases I presented, the one that I found most interesting was of 36-year-old Caucasian male with a past psychiatric history of bipolar disorder who was brought in by emergency medical service and NYPD (not under custody) which was activated by father for bizarre behavior. As per the triage note, “patient was intrusive and was seeking physician assisted suicide for the last 6 months.” Upon interview, patient was guarded, irritated, disorganized, illogical, tangential, and acutely psychotic. The patient was also suspicious with paranoid ideation. The patient reported that he had been in Switzerland for the last 10 months because he was an “advocate” for physician assisted suicide, and that he had just flown into JFK that day where he was met and followed by someone unknown to him who brought him to CPEP for psychiatric evaluation.

Writing the H&P for a psychiatric case was a little bit different for me compared to writing one for a case in medicine. For one, you don’t really adhere to OLDCARTS when writing the HPI; however, you must still tell a story in a way that another reader can follow. You also have to include parts of the mental status exam in your HPI. For example, I always like to include whether the patient was cooperative, their mood and affect, and if the patient’s insight and judgment are intact. In this case, my patient was guarded, irritated, disorganized, illogical, tangential, and acutely psychotic. I had to spend some time analyzing other providers’ examples of their H&Ps to get an idea of how to write HPIs and other parts of the H&P throughout my rotation. 

Among my differentials were the following:

• Bipolar disorder (manic episode) – The patient presented with a persistent expansive and elevated mood and increased goal-directed energy; particularly with the idea of pursuing physician assisted suicide. He is also very talkative with pressure speech and exhibits a flight of ideas. He is also illogical, paranoid with poor judgment and insight.
• Schizophrenia – The patient appeared to be internally preoccupied, distracted, guarded and indifferent. Again, speech is pressured and rapid, but thought process is tangential. 

His thought process is a flight of ideas and content is somewhat delusional. However, the patient does not seem to experience any hallucinations. I wouldn’t list this as my top differential as mania is not part of this diagnosis. 

• Substance abuse – The patient has a history of alcohol abuse which means he has a higher probability of abusing other illicit drugs or stimulants that could mimic his symptoms. Alcohol itself, however, is a depressant and wouldn’t present the same way. 
• Hyperthyroidism – It can cause restlessness, hyperactivity, insomnia and irritability – symptoms that could be mistaken for mania. 

Based on the feedback I received, my evaluator agreed with my top differential based on the findings that I presented. My plan for this patient was to get routine labs such as a CBC with differentials, CMP, urine toxicology screen, and EKG. I also suggested admitting the patient to CPEP for observation for the next 24 hours under 9.40 legal status, after which he would be re-evaluated for safe disposition. I recommended to start the patient on Lithium at 300 mg twice a day or three times a day, and order labs for thyroid (TSH, T3 & T4) and renal function (eGFR/crCl) as this medication can cause hypothyroidism and is eliminated by the kidneys. I would also monitor Lithium serum concentration levels closely as it has a narrow therapeutic index and cause Lithium toxicity. I also suggested adding Seroquel (Quetiapine) 150mg two times a day or 300mg once a day by mouth. My last recommendation for the patient was to follow up outpatient with a psychiatrist after discharge for maintenance treatment.