H&P

History

Identifying Data:

Full Name: S.V.

Address: N/A

Date of Birth: N/A

Date & Time: 01/18/2023, 11:00 am

Location: Queens Hospital Center

Religion: N/A

Source of Information: Self

Reliability: Unreliable

Source of Referral: Medical Emergency Room

Mode of Transport: EMS

Chief Complaint: “I was smoking marijuana and my asthma started acting up so I came here.”

History of Present Illness:

The patient is a 40-year-old Caucasian male, domiciled, unemployed, with a history of substance abuse (marijuana), past medical history of asthma, past psychiatric history of schizoaffective disorder, bipolar type, brought in by EMS, activated by fiancé, to the medical emergency room for suspected asthma exacerbation after smoking marijuana. Pt has inpatient hx at Lincoln hospital in 2021.Patient was cleared by the medical ER and transferred to CPEP for erratic behavior. Upon interview, patient is accelerated, hyperverbal, disorganized, labile, and bizarre. Patient also presents with rapid and pressured speech, tangential thought process, and requires constant verbal redirection. Patient is also intrusive, impulsive and unpredictable. Patient reports he was smoking marijuana and came to the medical ER for his asthma. Patient endorses a recent decrease in their need for sleep and an abundance of energy. He denies needing any psychiatric treatment and is preoccupied with discharge. Denies suicidal/homicidal ideation, auditory/visual hallucinations, but admits to smoking marijuana often.

Collateral information was obtained from the patient’s fiancé/home attendant Michelle (646-830-4821) who reports that the patient has a long history of hospitalization for bipolar disorder. She states that the patient is prescribed Lithium and Abilify, but doesn’t believe he is compliant with medications. She denies any alcohol or substance abuse other than marijuana. She also reports that he has had “delusional thoughts such as saying he speaks 54 languages.” She notes that he has recently not been sleeping well either. She also states that “I want him to stay in the hospital until he is back to normal.” 

Past Psychiatric History:

The patient has a history of psychosis, bipolar disorder, and schizoaffective disorder.

Past Medical History:

The patient has a past medical history of asthma, and no past surgical history.

Family History:

Family history is unknown.

Social History:

Mr. MM is engaged, unemployed and lives with is fiancé. 

Habits – The patient has a history of marijuana and tobacco use, but has no history of illicit drug use in his lifetime. Denies alcohol abuse.

Sexual History – The patient is heterosexual and is currently sexually active. 

Medications: 

Lithium, dosage unknown

Abilify, dosage unknown

Allergies:

No known drug allergy.

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 overweight & disheveled, but alert & oriented to time, place, and person. Also has good posture, but seems like an unreliable source of information. No signs of acute distress, appears as stated age.

Vital Signs:     BP: (R) Seated 119/74                        P:  87 beats/min, regular

                               (L) Seated 120/80

                        R: 16 breaths/min, unlabored             O2 Sat: 99% Room Air

                        T: 37.0 degrees C (oral)

                        Height: 1.85m             Weight: 90.9 kg          BMI: 27.1

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 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. SV is a tall and overweight elderly Caucasian male with black hair. He has no scars on his face or hands. He appears disheveled, but well-nourished, and has fair eye contact. 

2. Behavior and Psychomotor Activity: Mr. SV showed signs of psychomotor agitation. He kept pacing up and down the halls unable to sit still.

3. Attitude Towards Examiner: Mr. SV was guarded.

Sensorium and Cognition 

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

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

3. Concentration and Attention: Mr. CV’s level of concentration was poor with flight of ideas, but fair enough to illicit some information. He did not have sufficient sustained attention to perform tedious psychological testing. Mr. SV gave relevant responses to questions. 

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

5. Abstract Thinking: Mr. SV’s ability to abstract was poor as his thought process was disorganized, illogical with flight of ideas.

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

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

Mood and Affect 

1. Mood: Mr. SV’s mood was anxious, cheerful, nervous and irritable.
2. Affect: Mr. SV’s affect was labile.

3. Appropriateness: Mr. SV’s mood and affect were consistent with the topics he discussed. He exhibited labile emotions and uncontrollable crying at times. 

Motor 

1. Speech: Mr. SV’s speech was rapid and pressured. 
2. Eye Contact: Mr. SV made good eye contact.
3. Body Movements: Mr. SV had no extremity tremors or facial tics. 

Reasoning and Control 

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

2. Judgment: Mr. MM’s judgement was impaired. 

3. Insight: Mr. MM had poor insight into his psychiatric condition, the need for treatment and the need to take medications. 

Differential Diagnoses

• Schizoaffective, bipolar type
  • Patient was illogical, disorganized, delusional and labile with manic behavior. His speech was also loud, rapid, and pressured. His thought content was also a flight of ideas. Schizoaffective, bipolar type would be the most likely diagnosis based on his manic behavior and symptoms of schizophrenia.
• Schizophrenia
  • I included schizophrenia in my list of differentials because the patient presented with delusions and the patient was initially brought to the psychiatric emergency room for erratic behavior. However, schizophrenia doesn’t really fit the patient’s initial presentation of manic behavior. He also has a history of bipolar 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. 

• Substance abuse – The patient has a history of daily marijuana use which means he has a higher probability of abusing other illicit drugs or stimulants that could mimic his symptoms. Marijuana itself, however, can act as depressant, stimulant or hallucinogenic.
• Hyperthyroidism – It can cause restlessness, hyperactivity, insomnia and irritability – symptoms that could be mistaken for mania. 

Assessment

The patient is a 40-year-old Caucasian male, domiciled, unemployed, with a history of substance abuse (marijuana), past medical history of asthma, past psychiatric history of schizoaffective disorder, bipolar type, brought in by EMS, activated by fiancé, to the medical emergency room for erratic behavior most likely due to medication non-compliance. 

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 recommend restarting Lithium for this patient as it is first line, and he’s already been on it before. 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 restart Abilify 15 mg PO since he’s been on that as well. I would recommend for the patient to follow up outpatient with a psychiatrist after discharge for maintenance treatment.