H&P

History

Identifying Data:

Full Name: M.M.

Address: N/A

Date of Birth: N/A

Date & Time: 01/10/2023, 3:45 pm

Location: Queens Hospital Center

Religion: N/A

Source of Information: Self

Reliability: Reliable

Source of Referral: Medical Emergency Room

Mode of Transport: EMS

Chief Complaint: “I am not safe.”

History of Present Illness:

The patient is a 66-year-old African American male, unemployed, living at Venture House Scatter Side Apartment Program, with a reported past psychiatric history of schizoaffective disorder and past medical history of end-stage renal disease on hemodialysis via left upper graft who presents to the medical emergency room, brought in by Emergency Medical Services, which the housing manager called due to reported mood and behavioral changes attributed to the patient failing to take his medications. 

Upon psychiatric evaluation in the medical emergency room, patient presents with depressed mood, decreased emotional expression, and is guarded, withdrawn, and isolative. Patient appears malnourished and disheveled with signs of poor self-care. Patient admits to not taking his medications for approximately one month and admits to being paranoid, stating that “he is not safe,” however, he is unable to evaluate further. 

Additional information was obtained from the patient’s housing manager Ms. Jones (Phone number), who reports that the patient called him unexpectedly at 3am this morning and did not sound like his normal self, which prompted him to call Emergency Medical Services to be evaluated. The Federation of Organization ACT team was also contacted to obtain the patient’s medication regimen. As per the staff, the patient last received Invega Sustenna 234 mg intramuscularly on 12/19/22. 

Past Psychiatric History:

The patient has a history of manic depression, mood disorder, psychotic disorder, schizoaffective disorder, and dementia. The patient follows up with an outpatient mental health program.

Past Medical History:

The patient has a past medical history of acute kidney injury (7/7/21), aggressive behavior, bradycardia (9/20/18), COVID (10/15/21), dementia (8/22/13), hypertension (10/15/21), manic depression, mood disorder, psychotic disorder, schizoaffective disorder, and seizures. The patient also has a past surgical history that includes arteriovenous anastomosis open direct (left, 9/1/21).

Family History:

Family history is unknown.

Social History:

Mr. MM is single, unemployed and has housing through the Venture House Scatter Side Apartment Program.

Habits – The patient has a history of alcohol abuse. He started drinking in his early 20s, and the patient had drinks daily. It is unknown whether patient continues to drink alcohol. The patient denies any tobacco use or illicit drug use in his lifetime.

Sexual History – The patient is heterosexual and is not currently sexually active. 

Medications: 

Acetaminophen 325 mg, 2 tablets (650mg total) by mouth every 6 hours as needed

Aspirin, 81mg tablet, 1 tablet by mouth daily

Darbepoetin Alfa 60 mcg/0.3ml, inject 0.3mL (60mcg total) under skin once a week 

Multivitamin tablet, 1 tablet daily by mouth

Sodium Zirconium Cyclosilicate 10g Pack packet, 1 packet by mouth every 12 hours

Tamsulosin 0.4mg capsule, 1 capsule by mouth daily

Allergies:

Chlorpromazine – Reaction unknown.

Penicillin – Anaphylaxis 

Shellfish-Derived Products – Anaphylaxis

Review of Systems:

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. 

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. 

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). 

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.

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

Menstrual/Obstetrical – N/A

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

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 

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

Physical Exam:

General: Male appears disheveled & unkempt, malnourished, alert & oriented to time, place, and person. Also has good posture and but does not seem 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. Black 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 5^th 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. MM is a tall and thin elderly African American male with graying black hair. He has no scars on his face or hands. He appears disheveled, malnourished with signs of poor self-care, and poor eye contact.  MM’s physical appearance was consistent with an individual who was debilitated from end-stage renal disease.  

2. Behavior and Psychomotor Activity: Mr. MM showed no signs of abnormal psychomotor movement.

3. Attitude Towards Examiner: Mr. MM was guarded and uncooperative.

Sensorium and Cognition 

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

2. Orientation: Mr. MM was oriented to the time of day, the place of the exam and the date. 

3. Concentration and Attention: Mr. MM’s level of concentration was fair enough to illicit some information but withdrawn and unable to elaborate on his responses. He did not have sufficient sustained attention to perform tedious psychological testing. Mr. MM gave relevant responses to questions. 

4. Capacity to Read and Write: Mr. MM was unable to read due to limited concentration and attention.

5. Abstract Thinking: Mr. MM’s ability to abstract was fair, but difficult to really determine as patient was guarded, withdrawn and isolative.

6. Memory: Mr. MM’s remote and recent memory were normal. 

7. Fund of Information and Knowledge: Mr. MM’s intellectual performance was average, but consistent with his level of education (high school).

Mood and Affect 

1. Mood: Mr. MM’s mood was sad, depressed, and anxious.
2. Affect: Mr. MM’s affect was almost expressionless.  

3. Appropriateness: Mr. MM’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. MM’s speech was not very conversational. 
2. Eye Contact: Mr. MM made poor eye contact.
3. Body Movements: Mr. MM had no extremity tremors or facial tics. 

Reasoning and Control 

1. Impulse Control: Mr. MM’s impulse control was impaired but did not have suicidal or homicidal urges. 

2. Judgment: Mr. MM was paranoid, stating that “he is not safe.” He denied auditory or visual hallucination and delusions.

3. Insight: Mr. MM had fair insight into his psychiatric condition and the need to take medications. 

Differential Diagnoses

• Schizoaffective, bipolar type
  • The patient initially had mood and behavior changes; he was manic. He also had paranoid delusions. He also presented with negative symptoms that align more with schizophrenia, but his initial manic episode doesn’t fit the clinical picture.
• Schizophrenia
  • I included schizophrenia in my list of differentials because although the patient did not present with the classic positive symptoms of delusions or hallucinations, the patient was initially brought to the psychiatric emergency room for disorganized behavior. The patient also had paranoia, stating that “he is not safe.” Patient also presented with some negative symptoms including, lack of emotion, social withdrawal, and lack of speech. The patient also has some risk factors for schizophrenia such as, he is unmarried, born amid Winter and Spring, and has a history of alcohol abuse. However, schizophrenia doesn’t really fit the patient’s initial presentation of manic behavior. He also has a history of mood disorder which aligns more with the clinical picture of schizoaffective disorder which has a shorter duration and involves 2 weeks of psychosis that alternates with 2 or more weeks of a mood episode such as mania. 
• Psychosis due to an end-stage renal disease
  • The patient has end-stage renal disease which can cause some electrolyte abnormalities leading to altered mental status. He is also on dialysis which can also induce dialysis dementia which can mimic psychotic symptoms such as impaired abstract thinking. 
• Delirium
  • The patient has end-stage renal disease which can cause delirium in a patient. Delirium can cause a patient to become irritable, anxious, and disorientated. It can also cause psychomotor agitation and perceptual disturbances. Delirium is commonly associated with underlying physiologic conditions.

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 manic 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. At this time I would not consider continuing Invega Sustenna as patient was recently diagnosed with end-stage renal disease. I would instead suggest starting Abilify 10mg for the initial dose and then titrate up to 10 mg once a day as this medication is unlikely to be dialyzed and no supplemental dose or dosage adjustment is needed with his dialysis. As far as adding a mood stabilizer, Lithium has a relative contraindication for patients with ESRD. I would consider a dose of Depakote starting at 500 to 750 mg/day in 1 to 4 divided doses as there is no specific dosage adjustment necessary. At therapeutic concentrations, dialysis decreases valproic acid concentrations by 20%, but usually rebounds within a few hours after dialysis. Also, patient is scheduled for dialysis in one day. The plan is to stabilize patient for safe disposition and discharge so that he can make his dialysis appointment. Patient is to follow up with outpatient psychiatrist to discuss treatment plan moving forward with his new ESRD diagnosis and can no longer continue with Invega Sustenna.