Rotation 7

Identification:

Patient’s name: SE

Age: 40

Gender: M

Race: Hispanic

Location: Elmhurst Hospital, Psychiatric inpatient unit

Informant: self, reliable

CC: “I am going to kill myself.”

HPI:

40 y.o Hispanic male with hx of substance abuse BIBEMS activated by his manager/ friend after patient texted “I quit, I am going to kill myself.” Patient admitted to taking 30 pills of Aleve and consumed ½ gallon of liquor with intent to kill himself. Patient stated that he was feeling “sad and depressed” on assessment, and “I’m tired of living. My whole life, I should not have been born”. He had been feeling depressed ever since his mother passed away for 2.5 years. Patient reported worsening depression and passive suicidal ideation after he lost his job at Con Ed which he worked for 15 years. Patient explained that after he lost his job, his friend hired him as a construction worker and he had been attending work intermittently.  Patient endorsed poor appetite, poor sleep and concentration as well as low energy, anhedonia and feelings of guilt for ruining his and his children’s lives. Patient got divorced about 1.5 years ago and was no longer able to see his children due to his hx of substance abuse. He also had on-going conflicts with his wife. Patient stated that he drinks ½ to 1 gallon of EtOH every other day, smokes marijuana every other day, and uses heroin once a week. Patient identified his family and friends as protective factors. Denies homicidal ideation, hallucinations, delusion, previous hx of suicidal attempts/ideations, prior hx of inpatient admission and rehab, past psychiatric medication, manic symptoms, and hx of aggression.  As per collateral obtained from patient’s friend, patient had been quiet and socially isolated after the death of his mother. Patient also had been making hopeless statements. But this time was the first time he texted and expressed suicidal ideation.

PMH:

Denies PMHx

Past Surgical History:

Denies past surgical hx

Medications:

Denies taking medications

Allergies:

NKDA

Family History:

Patient refused to elaborate on family history, but reported that his mother is an alcoholic.

Social History:

Patient lives alone, divorced with wife and was no longer able to see his children. He has 2 children (9 and 14 years old) but does not have custody. Currently unemployed. Patient started to drink EtOH at age 10, smoke marijuana every other day since 18 y.o, and use heroin once a week since 18 y.o.

ROS:

General: Patient denies recent weight loss or weight gain, generalized weakness, fatigue, fever, chill or night sweats

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Breast: Patient denies lumps, nipple discharge, pain, or last mammogram

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool or stool guaiac test or colonoscopy

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain, hesitancy, dribbling or last prostate exam

Sexual history: Patient is not sexually active, denies impotence, or STD

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance or goiter

Psychiatric: Patient reports depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities. Patient denies anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications.

Physical Examination (performed by ED)

General: 40-year-old male is alert and cooperative. He is well dressed and doesn’t appear to be acute distressed. Fair grooming, looks like his stated age of 40 years old. Well developed.

Vital Signs:

BP (seated): 136/94 left arm, sitting

HR: 75 BMP, regular

RR:  18, not labored

Temp: 98.5 F oral

O2 sat: 100% room air

Height: 5’5.75” weight:156lbs  BMI: 25.37

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution

Nails: No clubbing.

Head: Normocephalic, atraumatic.

Eyes: Symmetrical OU; no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears.

Nose: Symmetrical with no masses, lesions, deformities, or trauma.

Sinuses: not performed

Lips: Pink, dry, no cyanosis or lesions

Mucosa: not performed

Palate: not performed

Teeth: not performed

Gingivae: not performed

Tongue: not performed

Oropharynx: not performed

Neck: No masses, lesions or scars. Trachea midline.

Thyroid: Nontender, no palpable masses, no thyromegaly, no bruits

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. No wheezing, crackles, rales.

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR. No JVD.

Abdomen: Flat, symmetrical, no scars, striae. Nontender to percussion or to light and deep palpation. No organomegaly, guarding, or rebound tenderness.

Male genitalia and hernia: not performed

Anus, rectum, and prostate: not performed

Rectal: not performed

Peripheral vascular: The extremities are normal in color, size and temperature. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted

Neurological

Mental status exam:

General:

Appearance: Pt was medium build, dressed in a hospital gown and fairly groomed. He was sitting comfortably in a chair. Appeared like his stated age.

Behavior and psychomotor activity: Patient was calm and cooperative, moderate psychomotor retardation.

Attitude: Patient was cooperative and willing to answer questions. He established rapport in about 3-5 minutes.

Sensorium and cognition:

Alertness and consciousness: Patient remained alert and conscious throughout the interview.

Orientation: Patient was oriented to the time of day, the place of the exam, and the date.

Capacity to read and write: Patient had fair reading and writing capacity.

Abstract thinking: Patient did not use English metaphor to explain things, but was still able to clarify his thoughts. Patient was able to do simple calculations to determine his children’s age and date. His ability to use deductive reasoning was fair.

Memory: Patient’s remote and recent memory were normal.

Fund of information and knowledge: Patient’s intellectual performance was consistent with his educational level.

Mood and affect:

Mood: sad and depressed

Affect: blunted, constricted and depressed

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

Motor:

Speech: Patient was speaking slowly and softly.

Eye contact: Patient was trying to avoid eye contact.

Body movement: Patient had no extremity tremors or facial tics. His body movements were decreased and slow. Gait is normal.

Reasoning and control:

Impulse control: Patient has fair impulse control. He expressed suicidal, but not homicidal urge.

Judgement: Patient had no paranoia, bizarre delusions, auditory or visual hallucinations. Patient has goal-direct, linear and logical thought process.

Insight: Patient had fair insight into his psychiatric condition and the need for medications.

Cranial nerve: not performed

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Gait normal with no ataxia.

Sensory: not performed

Reflexes: not performed

Musculoskeletal System/Upper extremities and lower extremities: No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Labs:

CBC: wnl

CMP: total protein 5.9 dec, AST 69 elevated, ALT 67 elevated

TSH: wnl

T4 free, T3: wnl

Acetaminophen level: <5

Salicylate: 0.3 dec

Blood alcohol level: 265 elevated

Lipid Panel: cholesterol 266 elevated

Syphilis: negative

Quan TB: negative

Urine drug screen: not collected

Assessment:

40 y.o Hispanic male with hx of substance abuse BIBEMS for suicidal ideations. Presentation is most consistent with major depressive disorder and polysubstance abuse.

Differential Diagnosis:

1. Major depressive disorder: Patient had persistent feelings of sadness, loss of interest in usual activities, guilt, changes in sleep, appetite, and concentration. Patient also had suicidal ideations.
2. Substance-induced depression: Patient had a history of substance abuse. Patient admitted to majriruana use every other day and heroin once a week. But urine drug screen was unable to collect from the patient.
3. Adjustment disorder: Patient reported that his mother passed away 2.5 years ago and he had been depressed ever since. Patient also lost his job at which he had worked for 15 years. This is less likely because it usually starts within 3 months of a stressful event and lasts no longer than 6 months.
4. Persistent depressive disorder: Patient had feelings of sadness, loss of interest in usual activities, guilt, changes in sleep, appetite, and concentration. Patient also had suicidal ideations. This is less likely because patient was never symptom-free in the 2-year period.
5. Bipolar disorder: Patient could be in the depression phase of bipolar disorder. But this is less likely as patient did not experienced any manic or hypomanic symptoms.

Plan:

1. EtOH abuse:

• Continue to monitor for s/s of EtOH withdrawal
• v/s q4h
• Thiamine 100mg po daily
• Folic acid 1 mg po daily
• Librium 25-50 mg po q6h prn
• Multivitamin 1 tab PO daily

1. Depression; high risk

• Inpatient admission for observation and stabilization
• Placed on 1:1 for suicidality
• Vital sign q4h
• Ativan PO 1mg q6h prn
• Mirtazapine 15mg PO nightly