Identifying Data:

Full Name: Mr. TK

Address: Queens, NY

Date of Birth: June 24, 1989

Date & Time: February 19^th, 2020

Location: Psych-ER/QHC

Religion: Catholic

Source of Information: Self

Source of Referral: Grandmother

Mode of Transport: EMS

Chief Complaint: “My grandma told EMS that I’m not acting like myself”.

HPI: Patient is a 31-year-old African-American single male, unemployed, domiciled in an apartment alone in Flushing, Queens with prior reported psych history of schizophrenia, no pmhx and no past substance use . BIBEMS, activated by patient’s grandmother (Ms. Shirley Evans xxx-xxx-3616) because patient was non-compliant with his medication and not acting like himself.

Patient was seen in CPEP where he was interviewed alone. On evaluation, patient showed poor self-care and hygiene, disheveled with ripped jeans, dirty jacket and food remains on his hair. When asked questions, patient seems to be irritable and showed poor judgment. Patient seemed to be internally preoccupied and somewhat paranoid. Patient stated that he lives alone but sees his grandmother almost every day. Patient stated that he works as a cashier at the supermarket across the street from his house and stated, “nothing is wrong with me, I don’t know why I’m here”. Patient stated that sometimes he doesn’t go to work because he thinks people at work are trying to hurt him and always talk about him, especially during night shifts. Patient stated, “There are times when I don’t sleep because they come to my window and stare at me all night” and last night he only got 4 hrs of sleep. He has gotten this amount of sleep for the past 3 days. When asked if he takes any medication, patient stated that he has schizophrenia and takes haloperidol and is compliant with his medication. Per patient, last time he took his medication was last week. Patient stated that he smokes 2-3 individual cigarettes a day, has been doing so for 3 years and denies any illicit drug use or alcohol use. Patient also denies suicidal ideation, homicidal ideation, visual hallucinations or decrease appetite.

Collateral information was obtained by the patient’s grandmother Ms. Shirley Evans. Grandmother stated that the patient lives by himself and was baseline last time she saw him which was 5 months ago. Ever since then, she did not hear from him or saw him at all. She became worried so she decided to go pay a visit at his house. Upon arrival, grandmother found the patient laying on the floor and stated, “his house was a complete mess, dirty clothes everywhere, broken glass and he smelled so bad”. Patient’s grandmother also noted that the patient’s medications were unused and unopened. When approached by grandmother to take him to the hospital, patient became confused and aggressive and that’s when grandmother decided to called EMS.

Past Medical History:

Patient denies any past medical hx.

​Past Surgical History:

Denies any past surgical history.

Medications:

IM haloperidol Decanoate-  2mg for long term care for schizophrenia, last dose was 3 months ago, per grandmother.

Allergies:

Denies any drug allergies.

Family History:

Patient denies any known family history of any psychiatric disorder. Adamantly denies

any family history of bipolar disorder, schizophrenia, and any suicide attempts.

Social History:

Mr.TK is a 31-year-old African-American male who lives by himself in an apartment in Flushing, Queens. He’s been living by himself for 2 years now and prior to this incident, he used to see his grandmother 2-3 times a week. Grandmother lives in Brooklyn and the mother of the patient is in Africa and has been there for the past 3 years as she’s trying to get a visa to visit soon. Patient does not know his father and stated that he allegedly never met him. Patient stated that he likes to draw and watch movie. Patient denies any recent travels and stated that he likes to eat chocolate chip cake once in a while. Patient stated he’s single and sexually inactive. He doesn’t really go out much and likes alone time. Patient’s highest level of education is a college degree in social studies. Per grandmother, patient has never smoked, alcohol abuse or illicit drug use. Grandmother stated, “He’s a good kid, we raised him well and try to take good care of him”. Mr. TK  was diagnosed with schizophrenia age 25. For the most part his schizophrenia has been under control and the patient has been compliant with his medications, however the grandmother is unsure what led Mr. TK to stop taking his mediations.

Review of Systems:

General: admits to not getting enough sleep and he feels tired. Denies recent weight loss or gain, loss of appetite, fever or chills, or night sweats.

Skin, hair, nails: denies changes in texture, excessive dryness/sweating, discoloration,

changes in pigmentation, moles/rashes, pruritus, changes in hair distribution

Head: denies vertigo, lightheadedness and head trauma

Eyes: denies blurring, diplopia, fatigue w/ eye use, scotoma, halos, lacrimation,

photophobia, pruritus and glasses use.

Ears: denies deafness, pain, discharge, tinnitus and hearing aid use.

Nose: denies discharge, epistaxis, obstruction.

Mouth/throat: denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice

changes and dentures.

Neck: denies localized swelling/lumps/stiffness and decreased ROM

Pulmonary: denies dyspnea, cough, wheezing, hemoptysis, cyanosis, orthopnea and PND.

Cardiovascular: denies chest pain, palpitations, edema/swelling of ankles/feet, syncope, known heart murmur.

Gastrointestinal: Denies intolerance to certain foods, N/V, dysphagia, loss of appetite,

pyrosis, abdominal pain, flatulence, eructation, diarrhea, jaundice, changes in bowel

habits, hemorrhoids, constipation, rectal bleeding, blood in stool, hx of GI bleed GU:

denies nocturia, dysuria, frequency, oliguria, polyuria, change in color of urine,

incontinence and flank pain.

Breast: denies lumps, nipple discharge and pain.

Musculoskeletal: Denies muscle fatigue, arthritis, muscle deformity/swelling and redness.

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

Hematological system: denies easy bruising, lymph node enlargement, anemia hx of DVT/PE.

Endocrine system: denies polyuria, polydipsia, polyphagia, heat or cold interlace, goiter,

excessive sweating, hirsutism.

Nervous: Denies seizures, LOC, numbness, paresthesia, dysesthesia, hyperesthesia,

ataxia, loss of strength, changes in cognition/mental status, weakness and trauma.

Psychiatric: Patient stated that he feels paranoid that someone is after him and watches him at night. He feels stressed out and anxious. Denies seeing a mental health professional and denies taking his psychiatric medications. See HPI for more.

Physical exam:

General: 31-year-old African-American male is alert and oriented x3, well-nourished, poor hygiene, distressed and agitated, sitting in slouched posture and appears older than his stated age.

Vital Signs:    BP:                              R                     L

Seated                       115/74               120/79

Supine                           111/75            121/73

R:        18/min unlabored                    P:         93, regular

T:         97.6 degrees F (oral)               O2 Sat: 96% Room air

Height 70 inches    Weight 180 lbs.    BMI: 25.8

Mental Status Exam:

General

1. Appearance: Mr. TK is a medium height and medium build African-American male with black, long hair. He shows poor hygiene with ripped jeans, dirty jacket and food remains on his hair. He appeared well-nourished/developed, slouched posture, and appeared older than his stated age.
2. Behavior and Psychomotor Activity: Mr. TK’s verbal responses initially were delayed and didn’t make eye contact with the interview. Patient kept touching his nails and very rarely raised his head up.
3. Attitude Towards Examiner: Mr. TK was reserved and internally occupied for half of the time during the interview. Some questions had to be repeated multiple times to get a response from patient. As the interview continued, patient opened up a bit more. Patient showed constant signs of paranoia by looking behind his back.

Sensorium and Cognition

1. Alertness and Consciousness: Mr. TK was alert and his level of consciousness did not change throughout the interview.
2. Orientation: Mr. TK was oriented to person, place of the exam, and the date. Patient knew who he was, the location of the hospital and today’s date.
3. Concentration and Attention: Mr. TK had poor ability to concentrate on most directions throughout the interview. Patient’s responses were not immediate and sometimes questions had to be repeated.
4. Capacity to Read and Write: Mr. TK had normal reading and writing ability. He was asked to write his grandmother’s number.
5. Abstract Thinking: Mr .TK was able to express abstract thinking. When asked, “what is a similarity between an apple and a banana?” patient stated, “They’re both fruits.” He was able to perform simple math when asked what’s 5+ 10 to which he said “15”.
6. Memory: Mr. TK’s recent, remote, and immediate memory were intact as he was able to recall where his mother was located and was able to recognize his grandmother.
7. Fund of Information and Knowledge: Mr. TK demonstrates average level of intelligence.

Mood and Affect

1. Mood: Mr. TK’s mood was a combination of sadness and depression.
2. Affect: Mr. TK’ affect was flat. Congruent with mood.
3. Appropriateness: Mr. TK’s mood and affect reflect depressive signs and symptoms. Patient did not exhibit angry outburst or crying.

Motor

1. Speech: Patient’s speech pattern was low in tone and slow.
2. Eye Contact: Patient had poor eye contact throughout the interview. Occasionally looked back behind him and looked paranoid.
3. Body Movements: Mr. TK had no extremity tremors or facial tics.

Reasoning and Control

1. Impulse Control: Mr. TK’s impulse control was satisfactory. Patient did not exhibit suicidal ideations and no suicidal plan. Patient stated he would hurt anyone who came to his house with the intent to hurt him.
2. Judgment: Patient’s judgement is impaired. He believes that the medication he was taking were poisoning him and that’s why he stopped taking them.
3. Insight: Mr. TK had poor insight into his psychiatric illness and the need

to take medications.

Assessment and Plan:

Patient is a 31-year-old African-American single male, unemployed, domiciled in an apartment alone in Flushing, Queens with prior reported psych history of schizophrenia, no pmhx and no past substance use . BIBEMS, activated by patient’s grandmother (Ms. Shirley Evans xxx-xxx-3616) because patient was non-compliant with his medication and not acting like himself.

Differential Diagnosis:

1) Schizophrenia: Patient already has prior history of schizophrenia and medications for schizophrenia was prescribed to control his symptoms. Mr. TK has not been taking his haloperidol which lead him to become more paranoid and delusional and also have auditory hallucinations that someone is after him and trying to hurt him.

2) Schizotypal: Patient exhibits 5 or more symptoms of schizotypal such as: suspiciousness, few close friends, paranoia, discomfort in social situations and magical thinking/ odd believes that someone is knocking on his window at night.

3) Substance-induced psychosis: Although grandmother denies illicit drug use and so does the pt himself, it can still be on our DDx until we do a urine tox and test for any illicit drug use. According to his grandmother, patient seemed to have an acute change from his normal baseline so these episodes could be induced by drugs.

Admit patient to CPEP for observation and monitoring.

1. First start pt on Haldol PO 5mg then once stable, start him on IM haloperidol decanoate 2mg for long term care.
2. order CBC, urinalysis, BMP, CMP to rule out any other possible causes of these symptoms.
3. make an appointment with a therapist and psychiatrist for outpatient follow up. Patient had one before but stopped going because he believed his symptoms were under control.
4. start CBT upon discharge.

At this time, patient is deemed to be a threat to himself, experiencing auditory hallucinations, and aggression, although he denies SI. Pt is in need of further psychiatric evaluation and requires overnight CPEP admission for observation and re-evaluation in the morning by

psychiatry. Patient is to be given a follow up outpatient appointment. Case discussed with attending doctor.

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