History

Identifying Data:
Full Name: A.R.
Address: N/A
Date of Birth: N/A
Date & Time: 01/09/2023, 11:00 am Location: Queens Hospital Center Religion: N/A

H&P

Source of Information: Self
Reliability: N/A
Source of Referral: Medical Emergency Room Mode of Transport: Emergency Medical Services

Chief Complaint: “I don’t know why I’m here; I flew into JFK today from Switzerland and someone met me and followed me at the airport and then was forced to come here.”

History of Present Illness:
The patient is a 36-year-old Caucasian male, domiciled, 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 is disorganized, illogical, tangential, and acutely psychotic. The patient is also suspicious with paranoid ideation. The patient reports that he had been in Switzerland for the last 10 months because he was an “advocate” for physician assisted suicide, and that he just flew into JFK today where he was met and followed by someone unknown to him who brought him to CPEP for psychiatric evaluation. The patient expresses strong feelings about having the right to decide whether to live or die and is upset that he is now back in the United States and is not able to die via physician assisted suicide. The patient is also very reluctant about giving any type of past history or demographic information that can provide more details about patient’s mental state and behavior/conduct in the past. The patient is very guarded and irritated stating that we are holding him against his will for reasons that someone said he was suicidal. Patient reports having a history of alcohol abuse in the past, but has been sober for the past 9 years. Denies any homicidal ideation, auditory/visual hallucinations, or illicit drug use at this time. Currently, not on any psychotropic medications and is not being seen outpatient by a therapist or psychiatrist. Collateral information was obtained from father who says he hired a detective who informed him that the patient flew in from Switzerland today. He also states that the patient was indeed in Switzerland for the last 6 months.

Past Medical/Surgical History:

Patient has past medical history of bipolar disorder. Patient has no past surgical history on file.

Past Psychiatric History:

Patient has a past psychiatric history of bipolar disorder.

Social History:

Mr. AR is single and lives alone.
Habits – The patient has a history of alcohol abuse but has been sober for the past 9 years. The patient denies any tobacco use or illicit drug use in his lifetime.
Travel – Recently traveled back from Switzerland on 1/09/23.
Diet – The patient states he is eating well.
Exercise – N/A
Safety Measures – Admits to wearing a seatbelt.
Sexual History – The patient is heterosexual and is not currently sexually active.

Substance Abuse History:

The patient has a history of alcohol abuse but has been sober for the past 9 years. The patient denies any tobacco use or illicit drug use in his lifetime.

Family History:

No pertinent family history.

Medications:

Currently not on any medications.

Allergies:

No known drug allergies.

Review of Systems:

Head – Denies headache, vertigo, or head trauma.
Eyes – Denies lacrimation, pruritus, visual disturbances or photophobia. Does not wear glasses. Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

General –Denies recent weight loss or gain, fever or chills, night sweats, loss of appetite, or generalized weakness/fatigue.

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Nose/sinuses – Denies discharge or epistaxis.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast – Denies lumps, nipple discharge, or pain.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures.

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Genitourinary system – Denies nocturia, dysuria, urinary frequency, urgency, oliguria, polyuria, incontinence, or flank pain.

Menstrual/Obstetrical – N/A

Nervous –Denies seizures, headache, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Peripheral vascular system – Denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins, or color changes.

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE. Denies blood transfusion.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Cardiovascular system –Denies irregular heartbeat, chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal system – Denies nausea, diarrhea and abdominal pain. Denies change in appetite, vomiting, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, or constipation.

Musculoskeletal system – Denies arthralgias, back pain, gait problems, joint deformity or

swelling, or redness.

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

Physical Exam:

General: Male appears clean & well-groomed, alert & oriented to time, place, and person. Also has good posture and seems like a reliable source of information. No signs of acute distress, appears as stated age.

Vital Signs: BP: (R) Seated 133/74 P: 88 beats/min, regular

(L) Seated 120/80

R: 17 breaths/min, unlabored O2 Sat: 99% Room Air T: 36.8 degrees C (oral)
Height: 1.753m Weight: 74.8 kg BMI: 24.37

Head, Skin, & Nails

Hair: Average quantity and distribution. White color. Straight texture. No evidence of lice or seborrheic dermatitis.
Skin: Warm and moist, smooth texture, good turgor.
Nails: No clubbing, capillary refill <2 seconds in upper and lower extremities

Head: Normocephalic, atraumatic, non-tender to palpation throughout.

Eye Exam

Eyes – Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/25 OS, 20/25 OD, 20/55 OU. Visual fields full OU. PERRLA, EOMs intact with no nystagmus.

Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.

Ear Exam

Symmetrical and appropriate in size. No lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/infarct with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midlines/Rhinne reveals AC>BC AU.

Nose & Sinuses Exam

Nose – Symmetrical/no masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No foreign bodies

Sinuses – Non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Mouth & Pharynx

Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink ; well hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. Non-tender to

Palpation; continuity intact.
Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.
Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation. Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies.
Tonsils present with no injection or exudate. Uvula pink, no edema, lesions

Neck Exam

Neck– Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted. Thorax & Lungs:

Chest – Symmetrical, no deformities, no trauma, Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to Ap diameter 2:1. Non-tender to palpation throughout.

Lungs –Clear to percussion & auscultation bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.

Cardiac Exam

Heart: JVP is 2.5cm above sternal angle with the head of the bed at 30 degrees. PMI in 5th ICS in midclavicular line. Carotid pulses are 2+ bilaterally without bruits. Irregular rate & rhythm. S1 & S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdominal Exam: Abdomen flat and symmetric with no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/iliac or femoral bruits. Non- tender to palpation and tympanic throughout, no guarding or rebounding noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Breast Exam: N/A Pelvic Exam: Genitalia: N/A

Rectal: No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.

Neurologic: Mental status: Patient is alert and oriented to person, place and time. Cranial nerves II-XII intact. Recent and remote memory is intact, attention, abstract thinking, and new learning ability are intact. Pt has good muscle bulk and tone with strength 5/5, no fasciculations. Cerebellar: Rapid alternative movements, finger to nose intact. Gait including normal stride, on toes, on heels, and tandem walking intact. Negative Romberg and Pronator Drift. Sensory: Pinprick, light touch, graphesthesia, stereognosis, position and vibration intact bilaterally.

Reflexes:

Biceps Triceps Brachioradialis Patellar Ankle/Achilles Babinski

Right 2+ 2+ 2+ 2+ 2+ absent Left 2+ 2+ 2+ 2+ 2+ absent

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.

Musculoskeletal (Upper Extremity): No soft tissue swelling / erythema /
ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally. No evidence of spinal deformities.

Mental Status Exam:

General

1. Appearance: Mr.AR is a young, tall, thin Caucasian male. He has no scars on his face or hands. He appears casually groomed, well-nourished and overall good hygiene. Patient maintains poor eye contact.

2. Behavior and Psychomotor Activity: Mr. AR showed signs of psychomotor agitation and appears to be responding to internal stimuli. Patient kept pacing back and forth down the halls.

3. Attitude Towards Examiner: Mr. AR was guarded and indifferent. He was reluctant about talking about his past or his family.

Sensorium and Cognition

1. Alertness and Consciousness: Mr. AR could maintain his consciousness throughout the interview.

2. Orientation: Mr. AR was oriented to the time of day, the place of the exam and the date.
3. Concentration and Attention: Mr. AR’s level of concentration was impaired; he had difficultyshifting mental attention. He did not have sufficient sustained attention to perform tediouspsychological testing. However, Mr. AR gave relevant responses to some questions.
4. Capacity to Read and Write: Mr. AR was unable to read due to limited concentration andattention.

6. Abstract Thinking: Mr. AR’s ability to abstract was concrete.
7. Memory: Mr. AR’s remote and recent memory were normal.
8. Fund of Information and Knowledge: Mr. AR’s intellectual performance was average, butconsistent with his level of education (high school).

Mood and Affect

1. Mood: Mr. AR’s mood was anxious.
2. Affect: Mr. AR’s affect was reactive.

3. Appropriateness: Mr. AR’s mood and affect were consistent with the topics he discussed. He did not exhibit labile emotions, angry outbursts, or uncontrollable crying.

Motor

1. Speech: Mr. AR’s speech was pressured, spontaneous and rapid. Volume was normal.
2. Eye Contact: Mr. AR made poor eye contact.
3. Body Movements: Mr. AR had no extremity tremors or facial tics.

Reasoning and Control

1. Impulse Control: Mr. AR’s impulse control was impaired and admitted to suicidal ideation and stating that he has a right to choose whether he gets to live or die but did not have homicidal urges.

2. Judgment: Mr. AR was paranoid, stating that “someone was following him.” He deniedauditory or visual hallucination and delusions.
3. Insight: Mr. AR did not have insight into his psychiatric condition and the need to takemedications. He believed that nothing is wrong with him and that he didn’t need to be here.

Differential Diagnoses:

• 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.

• Assessment:The patient is a 36-year-old Caucasian male, domiciled, with a past psychiatric history of bipolar disorder who was brought in by emergency medical service and NYPD (not under custody) presents for bizarre behavior most likely due untreated bipolar disorder.
• Plan/Treatment:Best plan of action currently is to get routine labs such as a CBC with differentials, CMP, BMP, urine toxicology screen, and EKG. Given patient’s bizarre behavior and psychotic symptoms, patient will also be accepted to CPEP for observation for the next 24 hours under 9.40 legal status, after which he will be re-evaluated for safe disposition. If patient still considered a danger to himself or others, consider admitting patient to start treatment. Treatment for this patient would include a mood stabilizer such as Lithium as it is first line. Lithium is initiated at 300 mg twice a day or three times a day, and the dose is then increased by 300 mg every 2–3 days to achieve blood levels of 0.8–1.2 meq/L. However, I would 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 would also add Seroquel (Quetiapine) 150mg two times a day or 300mg once a day by mouth. I would recommend for the patient to follow up outpatient with a psychiatrist after discharge for maintenance treatment.