History:

Date & time: 01/24/23 10:00 am

Full Name: PW

DOB: 01/10/1998

Address: Jamaica, NY 

Age: 25 y/o

Sex: Female 

Race: Hispanic

Religion: Christian 

Source: Pt. herself

Transportation: Self  

Reliability: Questionable  

Location: Jamaica, NY 

Chief Complaint: suicidal ideation in the context of “Ever since I found out I was pregnant I wanted to kill myself” x 10 days

History of Present Illness:

     25 y/o Hispanic female, currently 32 weeks pregnant, domiciled with aunt and grandma, unemployed, with past psychiatric history of postpartum depression and anxiety, presents to CPEP after voicing suicidal ideations to her OB today during her follow up. She states that ever since she found out she was pregnant 10 days ago she has felt like killing herself. She reports that she feels overwhelmed with this pregnancy and has a plan to overdose, when asked which medication she planned to overdose with she had no answer. She states that she was previously following up at Jamaica hospital outpatient clinic for depression and was taking sertraline but has not taken any medications in over a year. Pt. denies any homicidal ideations, auditory hallucinations, visual hallucinations, substance abuse, delusions, and paranoia.

     Pt provided collateral via aunt who states “She had postpartum with her first child who is now 9 months and ACS took the child and placed the baby under the father’s mother’s care. Now, the baby’s father did not want this baby and wanted her to have an abortion. The baby’s father is not calling her anymore and does not want anything to do with her. He told his mom the baby is not his and that she needs to get a DNA test. She feels alone and that he does not care about her, she wants to put the baby up for adoption. Whatever he is telling her is overwhelming her, he used to be with her 24/7 so this is a big adjustment for her”.  

Past Medical History:

• Postpartum depression x 1 year 
• self-reported anxiety x 1 year
• Immunizations status up to date.

Past Surgical History:

• Pt. reports she had eye surgery in 2018 no complications
• Pt. denies past blood transfusions. 

Treatment History:

• Pt. states she was being seen at Jamaica hospital outpatient. 

Medications:

• docusate sodium, 100 mg, PO, TID prn, for constipation. 
• prenatal multivitamin, 27-0.8 mg, PO, QD, for pregnancy 
• Denies use of any current psychiatric medications. 
• Denies use of herbal supplements.

Allergies:

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

Family History:

• Mother – alive and well age 51
• Father – deceased at unknown age and unknown reason
• Maternal/paternal grandparents – deceased at unknown age & unknown reasons

Social History:

• Habits- Pt. denies any prior or current abuse of drugs or alcohol. 
• Travel- Pt. denies any recent travel.
• Marital history- Pt. states she is single and has never been married 
• Occupational history- pt. refused to answer occupational history questions but states she is currently unemployed.
• Home situation- pt. states she lives with mom and aunt.
• Diet- Pt. refuses to answer questions about diet
• Exercise- Pt .refuses to answer questions about exercise. 
• Sexual Hx- Heterosexual, assigned female 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                        113/79                                               119/74

                  R: 18/min, unlabored                                               P: 88 beats/min, regular

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

                  Height: 62-inches              Weight: 165 lbs                  BMI: 21.2

Physical Exam:

Mental Status: 

General: 

1. Appearance: Ms. W is a short and heavy weight pregnant Hispanic female with long black hair. Her appearance was casually groomed and well appearing. Ms W’s physical appearance was consistent with an individual who is 7 months pregnant. 
2. Behavior and Psychomotor activity: Ms W’s behavior and psychomotor activity were within normal limits.
3. Attitude towards examiner: Ms. W was cooperative throughout the interview and answered most of the questions efficiently and holistically. 

Sensorium and cognition:

1. Alertness and consciousness: Pt. maintained appropriate alertness and consciousness throughout the interview. 
2. Orientation: Ms. W was oriented to time, place, and person. 
3. Concentration and attention: Ms. W’s concentration was fair throughout the exam, she was attentive, and gave relevant responses to questions. 
4. Capacity to read and write: When asked Ms.W was able to read the information on his wrist band. Unable to assess writing capacity due to lack of material at that moment. 
5. Abstract thinking: Ms. W used simple metaphors and allusions/allegories in English to convey her thoughts. She performed simple math equations when referencing her age in pivotal moments in his life and was able to estimate dates and quantify time in the sum of months or years. She showed the ability to use deductive reasoning as well.
6. Memory: Ms W’s remote and recent memory were unimpaired. 
7. Fundamental of information and knowledge: Ms W’s intellectual functioning was average.  

Mood and affect: 

1. Mood: Ms W’s mood was sad and depressed. 
2. Affect: Ms W’ s affect was appropriate throughout the interview. 
3. Appropriateness: Ms. W’s mood and affect were appropriate given that she felt sad and depressed currently, also given that she had active suicidal ideations. 

Motor: 

1. Speech: Ms W’s speech was appropriate with normal tone and volume throughout the interview. 
2. Eye contact: Ms. W had variable eye contact and avoided it during specific parts of the interview. 
3. Body movements: Ms.W displayed no noticeable body movements during the interview.  

Reasoning and Control: 

1. Impulse control: Ms. W displayed a lack of impulse control through a desire for instant gratification through wanting to commit suicide and having a plan. She denied any homicidal ideations
2. Judgment: Ms W’s  judgment was impaired again through her want to kill herself due to her being pregnant. She denies any auditory or visual hallucinations. 
3. Insight: Ms. W displays a mild lack of insight of the situation and why she should not kill herself simply because she is pregnant. 

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. Depression secondary to medicine noncompliance- Pt. reports a h/o of depression and states that she used to take medication however she stopped taking it for almost a year now. Pt. aunt reports that pt has a history of postpartum depression. Pt. aunt also describes many stressors that could be contributory such as recent break up and the first child being taken from her. Furthermore, she displays lack of insight and judgment through her want to kill herself.. 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 she 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. 

2. Psychoactive substance-induced psychosis: Even though patient is pregnant and states that she has no prior h/o substance abuse this still needs to be ruled out given that the patient is 25 y/o and has active suicidal ideations. In order to confirm this I would order a UTOX. I would also continue to observe the patient until stabilization.  

3. Bipolar II- According to pt and aunt pt. has a h/o depression and this current situation could be the presentation of a depressive episode. Pt. admits to suicidal ideations and plan to overdose on medications. In order to confirm, I would proceed to work with pt. getting a more detailed history and to identify symptoms and triggers, as well as educating the pt. on the illness. Lastly, I would prescribe a mood stabilizer such as lamotrigine.  

Plan: 

1. Admit to CPEP under 9.40 mental hygiene law for psychiatric evaluation, observation and stabilization until the patient is no longer a harm to herself which should take no longer than two days. 
2. Order ekg, LFTs, Thyroid function tests, CBC, and Utox
3. Give 25 mg of sertraline daily to control symptoms of depression.  
4. Schedule an outpatient psychiatry visit for the pt to follow up with, would also recommend that the pt consider seeing a therapist.