Identifying Data

Time: 11 AM, February 18, 2019

Name: C.H.

Sex: Female

Race: African American

Nationality: American

Marital Status: Single

Location: Elmhurst Hospital

Source of information: Self

Chief Complaint: Pt was brought to hospital for trespassing, she stated that was wasn’t doing anything, and that she was “waiting for her side n*gga” so they can smoke weed.

HPI

Miss C.H. is a 20 yo A.A. female, domiciled with boyfriend, with a PPH of schizoaffective disorder bipolar type, PTSD, and anxiety as per pts aunt. Pt was brought in to ED by EMS after being found by building’s superintendent while pt was leaning against a window, looking out and refusing to leave and stating that she lived there. As per ED notes, the patient had periods of being argumentative and slightly defensive, followed by periods when she was cheerful and laughing. Pt states that she didn’t do anything, and she was just being picked on because “they are crackers and I am black” she then stated that she was “waiting for her side n*gga” so they can smoke weed.

Psychiatric History

Schizoaffective Disorder

PTSD

Anxiety disorder

 

As per Aunt, pt has a long history of mental illness and sexual abuse. Pt was hospitalized numerous times until Creedmoor for 18 months with D/C in early 2018. Aunt reports that after D/C pt was doing well and was compliant with medications. In the beginning of the summer she became erratic, paranoid, disorganized, and ran away. She was missing for 3 months, until she suddenly called her aunt and reported being trafficked. Pt was sent to Bellevue and was discharged over-night. Pt then ran away and has since had minimal contact.

 

Trauma History

Pt is a commercially trafficked child.

Pt lived at her grandmother until the age of 12, at which point her grandmother kicked her out of the house after being caught shoplifting. The patient then dropped out of school and began prostituting, which she has continue on and off since then. Most recently the pt was prostituting prior to current hospitalization.

 

Hospitalization History

Creedmoor- 18 mo, D/C early 2018

 

Substance use history

Alcohol

Drugs: Molly, Ecstasy, Xanax (1-2x/week), Scissor, Marijuana (smoked 3 grams a day, daily)

Denies tobacco use

 

Family History

Mother- Schizophrenia

 

Medical History: None

Surgical History: none

 

Current Residence: unknown

Employment: unemployed

Education: 6^th grade

 

Medications

Benztropine 1 mg, PO, nightly

Clozapine 150 mg PO nightly

Clozapine 50 mg PO daily

Trazodone 200 mg PO nightly

 

PRN

Acetaminophen 650 mg PO Q6H PRN

Haloperidol 2 mg PO 4x daily PRN

Ibuprofen 400 mg PO Q8H PRN

Lorazepam 2 mg PO TID PRN

Polyethylene Glycol packet 17g PO Daily PRN

Sodium chloride 0.65% nasal spray 2 sprays each nostril TID PRN

 

Allergies: NKA

 

ROS

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

Skin, hair, and nails: denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritis and changes in hair distribution.

Head: denies headache, vertigo, head trauma, unconsciousness, coma, fracture.

Eyes: denies visual disturbances, fatigue, lacrimation, photophobia or pruritis.

Ears: denies deafness, pain, discharge, tinnitus, and hearing aids

Nose/sinuses: denies discharge, epistaxis, and obstruction

Mouth and Throat: denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, or dentures.

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

Breast: denies lumps, nipple discharge and pain

Pulmonary System: Denies dyspnea, orthopnea, SOB, PND, cough, wheezing, hemoptysis and cyanosis.

Cardiovascular: Denies HTN, edema, chest pain, palpitations, irregular heartbeat, and syncope.

Gastrointestinal system: Admits to constipation, denies abdominal pain, change in appetite, intolerance to foods, nausea, vomiting, hemorrhoids, dysphagia, pyrosis, flatulence, eructation, diarrhea, jaundice, change in bowel habits, rectal bleeding, blood in stool, pain in flank

Nervous: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system: Denies muscle/joint pain, deformity or swelling, redness or arthritis

Peripheral vascular system: denies varicose veins and peripheral edema intermittent claudication, coldness or trophic changes, or color change

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

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

 

Physical Exam

Vital Signs: BP 98/56, Pulse 74, Temp 97 (oral), RR 16, 02 100% room air

General: A/Ox3, she appears well developed, well nourished, she is active

Skin: warm and dry, no lesions noted

HEENT

Head: normocephalic, atraumatic

Ears: hearing, TMs, external ears and ear canal normal AU

Eyes: PERRLA, Conjunctiva, EOMs and lids are normal, no foreign bodies found

Neck: trachea midline, normal ROM, phonation normal, neck supple, no adenopathy

Cardiovascular: normal RR, normal S1, S2, no S3, S4, no gallops or murmurs, carotid pulses 2+ bilaterally without a bruit.

Pulmonary: normal breath sounds, no increased effort

Abdominal: soft, BS present all 4 quadrants

Musculoskeletal: Normal ROM and strength

Neurological: A/Ox3, strength and reflexes intact

 

Mental Status Exam

 

General

1. Appearance: Ms. C.H. is a medium height, medium build African American female. She has some small scars on her left forearm from previous cutting. Her hygiene is clean, and she is casually groomed.
2. Behavior and psychomotor activity: Ms. C.H. was sitting calmly in the beginning of the interview, she got restless as it progressed. She does not display any psychomotor slowing or delay.
3. Attitude toward examiner: Ms. C.H. is eager to talk to interviewer, she is cooperative, and rapport is easily established.

 

Sensorium and cognition

1. Alertness and consciousness: C.H. was alert, she remained so throughout the 30 minute interview, as well as after when she went to spend time with some of the other patients
2. Orientation: Ms. C.H. was oriented to person, place, time and the date.
3. Concentration and attention: Ms. C.H. was able to maintain concentration and attention to the subject matter throughout the interview
4. Capacity to read and write: Ms. C.H. has a satisfactory reading and writing ability.
5. Abstract thinking: Ms. C.H. was able to understand and use metaphors, she is able to calculate simple addition and subtraction in her head.
6. Memory: Ms. C.H.’s distant and recent memory were both intact
7. Fund of information and knowledge: Ms. C.H. displays decreased intelligence. This is consistent with her highest grade of completion of 6th grade.

 

Mood and Affect

1. Mood: Ms. C.H. is irritable and is easily set off by other pts on the unit.
2. Affect: Ms. C.H. is reactive
3. Appropriateness: Ms. C.H.’s mood and was appropriate and consistent with the topics discussed

 

Motor

1. Speech: Ms. C.H.’s speech is coherent and relevant
2. Eye contact: Ms. C.H. made appropriate eye contact
3. Body movements: Ms. C.H. has no extremity tremors or facial tics. Her body movements were appropriate

 

Reasoning and Control

1. Impulse control: Ms. C.H. has poor impulse control. She has been shown to throw things when she gets upset
2. Judgement: Ms. C.H. has poor judgement. She has auditory hallucinations of her grandmother. She has no paranoia or delusions
3. Insight: Ms. C.H. has very limited insight into her psychiatric condition.

 

DDx:

• Schizoaffective disorder- bipolar type
  • Pt exhibits auditory hallucinations in addition to an alternating mood disorder – both depression and mania
• Schizoaffective disorder- depressive type
  • Pt displays depression alternating with psychoses
  • Alternating mania makes bipolar type more likely
• Schizophrenia
  • Pt exhibits auditory hallucinations of her grandmother
  • Pt also exhibit disturbance in interpersonal relationships, occupations functioning and academic functioning as well as social functioning
  • The addition of a mood disorder makes schizoaffective more likely
• Borderline personality disorder
  • Patient exhibits impulsivity with sex and substance abuse
  • Pt has a short history of cutting at age 11
  • Pt exhibits reactivity of mood, and difficulty controlling anger
  • Pt does not show signs of avoiding abandonment, recurrent suicidal behavior, paranoia or dissociative symptoms, identity disturbance or a pattern of unstable relationships (no extremes in relationships)

 

Treatment Plan:

1. Stabilize psychotic symptoms with clozapine- emphasize medication adherence
2. Psychotherapy- with the goals of addressing triggers and improving insight in order to provide tools to maintain stability post discharge
3. Plan for safe discharge- most likely therapeutic foster home or group home.