Identifying Data:

Age: 29 years old

Sex: Female

Date of encounter: September 12^th, 2022

Location: Queen Hospital Center, Comprehensive Psychiatric Emergency Program

Race: Hispanic

Source of Information: Patient, mother, and EMS

Reliability: Reliable

 

Chief Complaint: Suicidal ideations

History of Present Illness:

Patient is a 29 year old Hispanic female, domiciled with both parents, divorced, currently unemployed, with past psychiatric history of major depressive disorder, and past medical history of migraines, cervical disc herniation, concussion syndrome, and chronic pain after a motor vehicle accident in April of 2019, brought in by EMS reportedly activated by psychiatrist during initial evaluation for social security at IMA Group Disability Services (phone #) in Kew Gardens, NY for suicidal ideations. The patient states she admitted to having suicidal ideations 3 days ago to the disability services officer today. When asked about a plan, the patient responded with, “I have a train station nearby.” She states that she does not have these suicidal thoughts currently. She states she has had suicidal thoughts intermittently throughout the past year, but denies prior attempts. Patient also mentions having difficulty falling asleep and maintaining sleep since her motor vehicle accident and decreased interest in activities she used to enjoy doing. Patient also notes taking Zoloft for the past month, as prescribed by her neurologist. She reports she has not seen improvement in her symptoms since starting this medication. Patient also mentions she has been looking forward to starting psychotherapy soon, but was told to wait until her clearance process with disability services was complete. Patient denies illicit substance use. She reports occasional drinking for social gatherings. Patient denies auditory or visual hallucinations. She denies homicidal ideations.

Collateral information was obtained from patient’s mother (insert name and phone # here) via Spanish interpreter (insert ID # here). Mother denies patient or familial past psychiatric history. She states her daughter has not been the same since the car accident which has changed her life, noting that the patient now spends most of her time isolated in her room and not socializing with anyone. Mother mentions that prior to the car accident, the patient was running a successful daycare business, but is now unemployed and seeking disability services. The day of the accident, patient was in the process of looking for houses to buy, but all of that changed once the collision happened. Mother denies noticing or mention of self-harm, suicidal ideations, homicidal ideations, auditory/visual hallucinations from her daughter. She denies any known illicit substance abuse by the patient.

 

 

Past Medical History:

Major depressive disorder – diagnosed by neurologist about 1 month ago.

Migraines – since car accident in April 2019

Cervical disc herniation – since car accident in April 2019

Concussion syndrome – since car accident in April 2019

 

Past Surgical History:
Bilateral knee procedures – patient did not specify what type or date, and did not bring records.

 

Medications:

Sertraline (Zoloft) 50mg, 1 tablet daily by mouth

Gabapentin 300mg, 1 tablet every night by mouth

Baclofen 20mg, 1 tablet three times a day by mouth

Celecoxib 200mg, 1 capsule twice a day by mouth

Methocarbamol 500mg, 1 tablet three times a day by mouth

Magnesium oxide 400mg, 1 tablet once a day by mouth

 

Allergies:

Denies any known drug, environmental, or food allergies.

 

Family History:

Patient and mother deny any significant family history.

 

Social History:

Patient lives with her parents. She is unemployed but used to run a daycare business.

Patient can perform ADLs independently, but ambulates with a cane.

Patient is divorced since 2020.

Habits – Denies caffeine use. Denies smoking history. (+)occasional alcohol use. Denies history of illicit substance use.

Sleep – (+)disturbance. Pt complains of difficulty falling asleep and maintain sleep. States she often sleeps for 1 hour at a time and then wakes up and goes back to sleep several times a night.

Travel – No recent travel.

 

Review of Systems:

General – Denies recent fever, chills, weight loss/gain, night sweats, or change in appetite.

Skin/nails – Denies rash, new moles, change in pigmentation, changes in hair distribution, or wounds.

Head – (+)headaches – (chronic migraines). Denies dizziness, lightheadedness, recent head trauma.

Eyes –Denies visual disturbances, photophobia.

Ears –Denies change in hearing, tinnitus, otalgia. No hearing aid use.

Nose – Denies congestion, discharge.

Mouth/throat – Denies sore throat, difficulty swallowing.

Neck – (+)pain – (chronic, cervical disc herniation).

Pulmonary – Denies SOB, cough.

Cardiovascular – Denies chest pain, palpitations, lower extremity swelling, syncope.

GI – Denies abdominal pain, nausea, vomiting, diarrhea, constipation.

Genitourinary – Denies incontinence, urgency, dysuria, hematuria, frequency.

Nervous – (+)gait change – (chronic, ambulates with cane). Denies seizures, confusion, weakness, numbness.

Musculoskeletal – (+)back pain, knee pain – (chronic after motor vehicle accident).

Psychiatric – (+)depression, suicidal thoughts. Denies hallucinations.

 

Physical Exam:

Vital signs:      BP: Seated                  L-arm: 129/85

RR:      18 breaths/min, unlabored

Pulse: 87  bpm, regular

T:        98.2 degrees F (oral)

O2 Sat: 98% on room air

Height: 5 ft 2 inches        Weight: 139 lbs.       BMI: 25.4

 

General: Pt alert, oriented. No acute distress. Well nourished. Looks stated age.

Skin: Skin is warm & moist. No ecchymosis. Nonicteric, no other lesions noted, no tattoos. No rashes appreciated.

Hair:  well distributed, no female pattern baldness.

Nails:  no clubbing

Head:   normocephalic, atraumatic

Ear: Symmetrical and appropriate in size.  No lesions, masses, on external ears.

Nose –Symmetrical. No masses, lesions, deformities, trauma, discharge.

Mouth/Oropharynx – Lips appear pink and moist, with no masses, cyanosis, or ulcers.

Eyes – Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white.

Chest/Pulmonary: Chest is symmetrical, without deformities or trauma. Lat to PA diameter is 2:1. Respirations unlabored.

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated.

Abdomen: Abdomen flat, symmetric.

Neurologic:

Cranial Nerves –Symmetric and fluid facial movements. No difficulty with BMP or LTND speech sounds. No hoarseness or nasal quality in voice. No facial droop.

Peripheral Neuro – Full active/passive ROM of upper extremities without rigidity or spasticity. Bilateral knees with limited ROM. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Gait unsteady without cane.

Musculoskeletal: (+)knee braces, bilateral. No soft tissue swelling / erythema / ecchymosis / atrophy in bilateral upper and lower extremities.

 

 

MENTAL STATUS EXAM:

General:

Appearance – Patient is a short height, young Hispanic female with red dyed hair. No scars on face or hands. Hygenic state was clean and clothes well kept. Bilateral knee braces in place, and patient ambulates steadily and slowly with a cane.

Behavior – patient is alert, no abnormal movements. No psychomotor slowing. She has slightly blunted facial expression and manner. Breathing is unlabored.

Attitude Towards Examiner: the patient appears mildly guarded, hesitant to give full details when answering questions.

 

Sensorium and Cognition:

Alertness and Consciousness: Patient is alert. Maintains consciousness throughout the interview and throughout her stay in the ED.

Orientation: Patient is oriented to time of day, date, and location

Concentration and Attention: Patient demonstrated satisfactory attention throughout the entire interview. Patient gave appropriate/relevant responses to questions. Conversation progresses logically towards a goal.

Capacity to Read and Write: Patient has good reading and writing ability

Abstract thinking: Patient used a few simple metaphors to explain things and clarify her thoughts.

Memory: Remote and recent memory were satisfactory. She was able to recall when her car accident happened, when she started Zoloft, and when her next doctor’s appointment was. She was able to tell me details about her old daycare.

Fund of information and knowledge: Intellectual performance was normal, consistent with her level of education (finished high school).

 

Mood and Affect:

Mood: Mood was dysphoric, and frustrated

Affect: Affect was slightly constricted and guarded.

Appropriateness: Patient’s mood and affect were as expected with current situation. She became tearful at times expressing her frustration with being the in the hospital, as she was convinced to come to the ED because she was told this would be a quick process. She reports concern with missing her doctor’s appointment tomorrow. Otherwise, she did not exhibit labile emotions, angry outburst, or uncontrollable crying.

 

Motor:

Speech: Patient speaks slowly but calmly, in soft tone. Speech is of slightly limited quantity (slightly constricted affect), but appropriate flow and articulation.

Eye contact: Adequate

Body Movements: Body movements were appropriate except for gait, which was slow and needed cane due to disability. No extremity tremors or facial tics.

 

Reasoning and Control:

Impulse control: Pt admits to having suicidal thoughts 3 days ago, but states they have since resolved. No homicidal urges. No feelings of rage or anxiety.

Judgement: No paranoia, bizarre delusions, obsessions, auditory or visual hallucinations.

Insight: Fair insight into psychiatric condition. Patient is aware of her depression and recent suicidal thoughts, but does not believe she needs to stay in the emergency department due to this. She reports compliance with her antidepressant.

 

 

LABS:

Complete metabolic panel : Within normal limits

Complete blood count : Within normal limits

HCG: negative

Glucose: 99

COVID, influenza A, influenza B: negative

Alcohol level: <10 mg/dL

Urine drug screen, TSH: ordered but not collected

 

 

Differential Diagnoses:

• Major depressive disorder – Consistent with story/complaints, and patient meets DSM-5 criteria (depressed mood, loss of interest, sleep change, fatigue, suicidality, etc).
• Post-traumatic stress disorder – Considered this due to the traumatic experience of the car accident with started her mood disturbances, however, this diagnosis was not chosen because patient denies flashbacks or other intrusive symptoms. Does not meet DSM-5 criteria.
• Bipolar disorder (type I or II) – Considered due to depressive symptoms, but this diagnosis is not likely because patient denies manic symptoms currently or in the past. No grandiosity, increased talkativeness, racing thoughts, attention deficit, psychomotor agitation, or activities with distressing consequences.
• Cyclothymic disorder – Chosen due to dysphoric nature of complaints, but not chosen as primary diagnosis because patient describes depression to be consistent throughout the year (>2 months).

 

Assessment:  29 y/o Hispanic female with history of major depressive disorder (started on Zoloft 50mg daily about 1 month ago), and multiple medical issues status post car accident in April 2019, sent to emergency department today from disability services office after patient mentioned having suicidal thoughts 3 days ago, involving train station near her home.

 

Plan:

Keep patient in CPEP overnight for further observation and stabilization, to maintain safety of the patient. Given suicidal ideations and mention of possible plan involving train station near her home, patient poses threat to herself at this time, despite claims that she has no suicidal thoughts today. Plan to create safety plan with the patient and check patient’s understanding of the plan. If this is successful and patient still adamantly denies current suicidal thoughts, patient may be discharged with outpatient follow up given appropriate support from family at home. Will discuss with social worker to set up outpatient follow up.

Education: advise patient that although she has not noticed a difference in her mood after taking Zoloft for 1 month, that this medication may take up to 6 weeks until an effect is noticed. Encourage patient to continue as prescribed. Recommend that if she still feels the same after 6 weeks, to inform outpatient provider so they can discuss alternative options.

Return precautions: Patient instructed to return to the emergency department if she experiences suicidal ideations, thoughts of wanting to hurt self or others, or any other concerns.