History:

Date & time: 01/08/23 10:00 am

Full Name: JC

DOB: 01/04/1992

Address: Jamaica, NY 

Age: 30 y/o

Sex: Male 

Race: Hispanic

Religion: Christian 

Source: Pt. himself

Transportation: Self  

Reliability: Questionable  

Location: Jamaica, NY 

Chief Complaint: erratic behavior in the context of “MS 13 is trying to kill me” x 1 day

History of Present Illness:

     30 y/o Latino male undomiciled, single, unemployed with PMH of substance abuse (cocaine, heroin) and self reported anxiety and depression BIBEMS/NYPD (not under arrest) for erratic behavior and psychiatric evaluation in the context of substance abuse. As per police report pt. called 911 because he thought someone was chasing him and jumped onto the LIRR train tracks and ran down the tracks. Upon evaluation at CPEP pt appears anxious and restless but cooperative, alert and oriented x ¾, guarded and paranoid with labile affect and irritable mood with mood swings, and somewhat disorganized and illogical thought process. Pt. denies suicidal ideation, auditory hallucinations, visual hallucinations, and changes in sleep and appetite at this time. Pt. presents with poor self care and is disheveled. Pt. displays poor insight, judgment, and impulse control. 

Pt. states that MS13 was chasing him and wanted to “set me up” and he was fearful they might kill him so he ran on the tracks to escape and EMS brought him to the hospital. Pt. reports he was “speed balling” earlier and injected heroin and cocaine prior to this incidence. Pt. reports he uses cocaine and heroin daily and states he has a history of depression and currently feels depressed at the moment. Pt. admits that he does not know any MS13 members or why they would want to harm him. Pt. reports that he did not run on the tracks as an attempt at suicide but to save his life. Pt. reports that his father has Bipolar d/o. Pt. denies any acute medical complaints. 

Pt. provided mother as collateral upon contact she states the pt has a diagnosis of “severe depression” and possibly bipolar d/o and was hospitalized a few months ago for trying to jump off a building and believes he is currently suicidal and needs help. Mother states pt injects drugs possibly to self medicate for depression and is dangerous, unstable, and needs psychiatric stabilization with drug treatment. 

Past Medical History:

• Polysubstance abuse x 5 years 
• Substance induced psychotic disorder 
• self-reported anxiety and depression x 5 years 
• Immunizations status unknown.

Past Surgical History:

• Pt. denies past surgeries or blood transfusions. 

Treatment History:

• Inpatient Rehab program 
• Outpatient Mental health practitioner 

Medications:

• Pt. denies the use of any prescribed/outpatient medications. 
• Denies use of herbal supplements.

Allergies:

• NKDA
• Denies seasonal, food, and animal allergies. 

Family History:

• Mother – alive and well age 63 
• Father – alive age 67 h/o bipolar disorder
• Maternal/paternal grandparents – deceased at unknown age & unknown reasons

Social History:

• Habits- Pt. reports current daily abuse of cocaine and heroin. Pt. admits to past abuse of alcohol and cannabis. Pt. denies any other prior or current substance abuse. 
• Travel- Pt. denies any recent travel.
• Marital history- Pt. states he is single and has never been married 
• Occupational history- pt. refused to answer occupational history questions.
• Home situation- pt. states he is homeless but often stays at his mother’s house.
• Diet- Pt. refuses to answer questions about diet
• Exercise- Pt .refuses to answer questions about exercise. 
• Sexual Hx- Heterosexual, assigned male sex at birth. Denies to answer questions about history of sexually transmitted diseases.
• Education: Pt. refuses to answer questions about education history.

Review of Systems:

General – Denies fever, night sweats, weight loss or gain, generalized fatigue, chills, changes in appetite. 

Skin, hair, nails – Denies changes in texture, excessive dryness, pigmentations, moles/rashes, pruritus, excessive sweating, or changes in hair distribution, 

Head – Denies headaches, vertigo, or head trauma, dizziness

Eyes – Denies glasses or contact usage, Last eye exam unknown visual acuity unknown. Denies glasses or contact usage, visual disturbances, photophobia, lacrimation, or pruritus.

Ears – Denies deafness, pain, discharge, tinnitus.

Nose/sinuses –Denies discharge obstruction, or epistaxis.

Mouth/throat – Last dental exam unknown. Denies sore throat, bleeding gums, sore tongue, mouth ulcers, or voice changes. 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion 

Breast – Denies lumps, nipple discharge, or pain. 

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – Denies palpitations, chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal system – Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool. 

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.

Nervous –Denies seizures, loss of consciousness, migraines, sensory disturbances, ataxia, loss of strength, changes in cognition / mental status / memory, or weakness.

Musculoskeletal system –Denies muscle/joint pain, deformity or swelling, or redness.

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

Hematological system –Denies anemia, 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

Psychiatric – Denies anxiety, OCD or ever seeing a mental health professional. Pt. has h/o of depression. 

Physical: 

General: Medium sized male, disheveled in appearance, looks older than her stated age of 30 years

Vital Signs: BP:                             R                                                       L

                  Seated                        133/89                                               131/84

                  R: 18/min, unlabored                                               P: 98 beats/min, regular

                  T: 98.6 degrees F (oral)                                         O2 Sat: 96% Room air

                  Height: 72-inches              Weight: 195 lbs                  BMI: 26.4

Physical Exam:

Mental Status: 

General: 

1. Appearance: Mr. C. is a medium height and weight Hispanic male with long black hair. He has multiple scars on his face and hands as well as track marks along his arms. His hygienic state was very unkempt and disheveled. Mr. C’s physical appearance was consistent with an individual who is debilitated from polysubstance abuse and homelessness. 
2. Behavior and Psychomotor activity: Mr. C’s behavior and psychomotor activity were restless with hyperverbal responses and increased motor activity via leg shaking and fidgeting of fingers. 
3. Attitude towards examiner: Mr. C was very guarded during the interview and refused to answer portions of the history and was hesitant to answer many questions that he did. 

Sensorium and cognition:

1. Alertness and consciousness: Pt. maintained appropriate alertness and consciousness throughout the interview. 
2. Orientation: Mr. C was oriented to time, place, and person. 
3. Concentration and attention: Mr. C’s concentration was fair throughout the exam and attention was limited. He did not have sufficient sustained attention to perform tedious physiological testing. He did, however, give relevant responses to questions. 
4. Capacity to read and write: When asked Mr. C was able to read the information on his wrist band. Unable to assess writing capacity due to lack of attention. 
5. Abstract thinking: Mr. C used simple metaphors and allusions/allegories in English to convey his thoughts. He performed simple math equations when referencing his age in pivotal moments in his life and was able to estimate dates and quantify time in the sum of months or years. His ability to use deductive reasoning was limited due to lack of logical thinking. 
6. Memory: Mr. C’s remote and recent memory were unimpaired. 
7. Fundamental of information and knowledge: Mr. C’s intellectual functioning was average and consistent with his h/o polysubstance abuse.  

Mood and affect: 

1. Mood: Mr. C’s mood was anxious and preoccupied with paranoia
2. Affect: Mr. C’ s affect was labile and constantly changing throughout the interview depending on what was being talked about. 
3. Appropriateness: Mr. C’s mood and affect were variable depending on the topic of discussion. He exhibited labile emotions, unwarranted outbursts, and demonstrated lack of control of emotions. 

Motor: 

1. Speech: Mr. C’s speech was hyperverbal and variable in tone and volume. 
2. Eye contact: Mr. C had variable eye contact and avoided it during specific parts of the interview. 
3. Body movements: Mr. C had restless body movements which displayed through leg shaking and fidgeting of the fingers. His gait was steady and intact. 

Reasoning and Control: 

1. Impulse control: Mr. C displayed lack of impulse control through a desire for instant gratification through both the history he provided and during the interview. He denies any current suicidal or homicidal ideations.
2. Judgment: Mr. C’s  judgment was impaired through his paranoid ideas of the belief that “MS 13 was trying to kill him” after substance abuse. His sense of perception displayed derealization. He denies any auditory or visual hallucinations. 
3. Insight: Mr. C displays a severe lack of insight of the situation and why he was at the hospital due to his ongoing paranoid ideas. 

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

Hair: average quantity and distribution. 

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non-tender to palpation throughout (could not appreciate do to EEG)

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.

Ears: Symmetrical and appropriate in size. No lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM pearly grey / intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.

Lips – Pink, moist; no cyanosis or lesions.

Mucosa – Pink; well hydrated. No masses: lesions noted. No leukoplakia. 

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars.  

Teeth – Good dentition / no obvious dental caries noted. 

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. 

Tongue – Pink; well papillated; no masses, lesions, or deviation. 

Oropharynx – Well hydrated; no injection, exudates, masses, lesions, or foreign bodies.

Tonsils grade 1 present with no injection or exudates. Uvula pink, no edema or lesions.

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.

Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 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.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. non-tender to palpation throughout. 

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Heart: JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Breasts: Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions.  No axillary nodes palpable

Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Male Genetalia and Hernias: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Anus, Rectum, and Prostate: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown. 

Motor/Cerebellar : Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.  Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Cranial Nerves: II-XII intact

Sensory:Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Reflexes: 2+ throughout, negative Babinski, no clonus appreciated 

Meningeal Signs:No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

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.

Differential diagnosis: 

1. Psychoactive substance-induced psychosis: Pt. admits to use of both cocaine and heroin prior to the incident. Pt. also states that he had paranoia that MS13 was going to kill him. He also reports no known history of schizophrenia. In order to confirm this I would order a UTOX and treat the pt symptomatically with a second generation antipsychotic such as olanzapine to manage the paranoia. I would also continue to observe the patient until stabilization.  
2. Brief psychotic disorder: Pt. reports sudden onset of psychotic symptoms and his symptoms of delusion and paranoia have only lasted for one day. In order to confirm, I would simply observe the patient because total remission will occur. I would also explore symptomatic treatment to manage the patient’s paranoia and delusions if they proved incapacitating.   
3. Bipolar I- According to mother pt. has a h/o “severe depression” and this current situation could be the presentation of a manic episode. Mother also states there is a family h/o Bipolar. Pt. had an irritable mood upon interview. Pt. admits to the paranoia and delusion of people trying to kill him. Furthermore, he displayed poor judgment by jumping onto the train tracks. In order to confirm, I would proceed to work with pt. to identify symptoms and triggers, as well as educating the pt. on the illness. Lastly, I would prescribe a mood stabilizer such as lithium, valproate, or lamotrigine.  
4. Depression- Pt. mother reports that pt. has a h/o depression and even a past suicide attempt of trying to jump of a building a few months ago. Even though pt denies that this situation of jumping on the the train tracks was an attempt at suicide, it must still be considered given the pt having a past suicide attempt and a possible h/o of depression. Pt. also reports h/o anxiety and was agitated on evaluation. Furthermore, he displays cognitive disturbances through his paranoia and delusions. First, I would order lab tests such as an ekg, LFTs, Thyroid function tests, and CBC to rule out any underlying medical reasons for depression. Then I would observe the pt to make sure he is not a threat to himself or others. Lastly, I would prescribe a SSRI such as zoloft and have the pt. follow up with an outpatient facility. 

Plan: 

1. Admit to CPEP under 9.40 mental hygiene law for psychiatric evaluation, observation and stabilization which should take no longer than two days. 
2. Order ekg, LFTs, Thyroid function tests, CBC, and Utox
3. Give 10 mg of olanzapine daily to control symptoms of paranoia.  
4. Recommend that the pt. seek rehab and opiate maintenance program for polysubstance abuse.
5. Schedule an outpatient psychiatry visit for the pt to follow up with, would also recommend that the pt consider seeing a therapist.