Sonam Bhandari, Date: 02/23/2021 Elmhurst Hospital – Inpatient Psychiatry

Identifying Information:

Name: KS
Date of Birth: XX/XX/1993 (27-year-old)
Race: Indian
Sex: Male
Address: Queens, NY
Date & Time: February 22 , 2021, 11:00 am Location: Elmhurst Hospital, Elmhurst, Queens NY Religion: Sikh
Source of Information: Self and chart review Reliability: Somewhat unreliable

Chief Complaint: Mr. KS was transferred from QHC, admitted for agitation and aggression at home, due to Positive COVID-19 results.

Mr. KS is a 27-year-old single Indian, Hindi and Punjabi speaking male living with his sister and her family, with no past medical history and a significant past psychiatric history of depression, treated for depressive symptoms on 6/2/2020 at QHC CPEP, referred to outpatient treatment with noncompliance. Patient was initially admitted to QHC, brought in by EMS for agitation and aggression at home, and transferred to Elmhurst hospital COVID psychiatry unit due to positive COVID-19 (on 2/17/2021) with legal status 9.27 for further assessment and stabilization.

In QHC patient was irritable, disorganized, paranoid, illogical, hyperverbal and was given STAT IM Haldol 5 mg and IM Ativan 2 mg 2 times due to aggressive behavior since he refused scheduled meds (Risperidone 1 mg BID). He stated mild EPS – stiffness in left arm and leg.
Patient evaluation was done via translation in Punjabi. Patient stated he became agitated due to constant nagging regarding his COVID positive results leading him to become agitated, rip off his shirt and break items in the house that led to his hospitalization. Although he was agitated patient denies thoughts or intent of hurting his sister or anyone in his family. He appears very sad and tearful and states that he misses home and regrets acting the way he did. While he denies feeling depressed, he previously stated having depressive symptoms since 2014 and also stated having COVID-19 since he was 10 years old, which he refuted by saying “I went to hospital for covid last year.” Initially he endorsed persecutory delusions by stating “people are talking about me, my family, and friends, they want to hurt me” but was unable to elaborate the details. Reported AH stating hearing a musical sound like “zzzzz” since last 6 months intermittently but no visual hallucination. He has poor insight into his illness and states “There is no need for me to be here, I am fine, being here is making me sicker.” He states that he has learned from his mistake and will never repeat it again, since he now knows what happens when he is aggressive. While the patient is calm and cooperative during the examination; he is preoccupied with discharge. He also remains with symptoms of aggressive outbursts and periodic loss of behavioral control. Patient is seen pacing the hallways, reports feeling restless, and anxious. Patient states inability to sleep well in the hospital and also sometimes at home.

Mr. S denies any appetite changes, fatigue, difficulty concentrating, grandiose beliefs. In the past, patient admitted to suicidal attempt by putting a sock in his mouth to choke himself and thought to drink bleach but did not. Currently denies any delusions, suicidal ideation, Homicidal ideation, Auditory/Visual hallucinations. Patient denies any physical pain, shortness of breath, cough, chest pain, fever, night sweats, or chills.

Past Medical History: No significant PMHx
Past Psychiatric History: Depressive mood, anxiety – 06/02/2020

Past Surgical History:

Denies any surgeries
Denies past injuries or blood transfusions.

Medications:

Denies use of medication or herbal supplements.

Allergies:

Dog – Hives
Eggs- Hives- resolved 10-12 years ago

Family History:

Patient denies any known family history of psychiatric disorder. Mother – 53, Alive and well.
Father – 59, Alive and well.
Brother and sister: alive and well.

Social History:

Patient is a single male, who resides with his sister, brother-in-law, his niece, and nephew. He currently works as an uber driver. Admits to difficulty sleeping at times but usually gets 8-9 hours of sleep a day. He admits to smoking about 2-3 cigarettes every few months and drinking a peg of whiskey most nights after work. He states a healthy diet consisting of fruits and vegetables and a good appetite. He denied use of illicit drugs.

Review of Systems:

Head – Denies headaches, vertigo or head trauma.
Eyes – Denies any visual disturbances, or photophobia.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids. Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mental Status Exam:

General

1. Appearance: Mr. S is a medium height, overweight Indian man with short black hair. He is dressed in the hospital gown, is well groomed. He is not in any acute distress. He has no visible scars, or tattoos. He appears his stated age.
2. Behavior and psychomotor Activity: Mr. S did not show ant psychomotor agitation or retardation.
3. Attitude toward examiner: Mr. S is cooperative throughout the interview.

Sensorium and Cognition

1. Alertness and Consciousness: Mr. S was alert throughout the interview.
2. Orientation: Mr. S is oriented to person, place, date and time.
3. Concentration and Attention: Mr. S had good concentration throughout the interview and

   answered all questions thoroughly.

4. Capacity to read and write Mr. S has fair ability to write and read in English.
5. Abstract thinking: Mr. S can compare and contrast similarities and differences in objects.
6. Memory: Mr. S’s remote and recent memory were both satisfactory.
7. Fund of Information and Knowledge: Mr. S demonstrates average intelligence.

Mood and Affect:

1. Mood: Mr. S states that he is feeling fine but is sad to be here at the hospital and is missing home and his family. He also stated feeling regretful of the way he behaved at home.
2. Affect: Mr. S’s affect was sad, congruent to his mood.
3. Appropriateness: Mr. S’s mood and affect both reflected his depressed mood.

Motor:

1. Speech: Mr. S spoke in Punjabi and Hindi; he speaks in a normal rate and regular rhythm.
2. Eye Contact: Mr. S made good eye contact while speaking and listening.
3. Body movements: Mr. S has a steady gait, no extremity tremors or facial tics. His

   movements were purposeful.

Reasoning and Control:

1. Impulse control: History of violence, aggression and Suicidal attempt/ideation. Currently denies Suicidal or homicidal ideation.
2. Judgement: Currently compliant with medication/treatment maybe superficially compliant to leave the hospital. Denies Auditory or visual hallucinations, paranoia, or delusions.
3. Insight: Mr. S has poor insight into his psychiatric condition and denies the need to be at the hospital. Although he does realize his aggression was unwarranted, he does not believe that is due to his psychiatric condition.

VITAL SIGNS:

BP: 131/70 (right arm) PULSE: 95
RR: 18 bpm
Height: 5’11”

Weight: 217 lbs BMI: 30.27 kg/m2 Temp: 97.6 F SpO2: 99%

Differential Diagnosis:

1. Schizophreniform: Patient presented with psychotic symptoms that include delusions of

   persecution, hallucinations and disorganized behavior. He was aggressive and agitated. Patient is presenting with symptoms of schizophrenia, but the symptoms have only been recently presented, the timeline needs to be assessed further for accurate diagnosis.

2. Schizophrenia: Patient is currently admitted due to aggression and agitation. He presented with delusions of persecution “everyone is trying to hurt me”, auditory hallucination for the last 6 months, and disorganized speech. In males schizophrenia peaks between 17-30. The timeline of the presenting symptoms needs to be assessed further (>6 months) to diagnose the patient with schizophrenia
3. Major Depressive Disorder, recurrent episode, with psychotic features: Patient presented with depressive mood – loss of appetite, insomnia, Suicidal ideation, inconsolable crying, anhedonia for 2 months before going to QHC ED on 06/02/2020. He did not seek outpatient treatment. Patient admits sleep disturbance, depressed mood, psychomotor agitation, previous suicidal attempt/ideation. Patient also has Psychosis including delusions, hallucinations, and disorganized speech.
4. Persistent depressive disorder: Patient stated feeling depressive mood since 2014 after moving to the US and states feeling down intermittently. However, this is less likely since patient does not state depressed mood nearly every day and does not state changes in appetite, fatigue or low energy, poor concentration, changes in sleep, or low self- esteem and due to his presenting psychosis.

Assessment: 27-year-old single male, domiciled with sister and her family, employed as an uber driver, no significant PMH and a PPH of depression admitted initially to QHC due to agitation, aggression at home and transferred to inpatient psychiatry unit B-9 due to a positive Covid-19 result on 2/19/2021. Patient previously went to QHC ED due to depressive symptoms on 6/2/2020 where he was referred for aftercare for mental health to Catholic charity which was not utilized. Patient was given PRN medication in QHC CPEP due to noncompliance with scheduled meds after which he developed mild EPS. Patient presents with psychotic symptoms that include delusions of persecution, hallucinations and disorganized behavior. In the past, patient admitted to suicidal attempt by putting a sock in his mouth to choke himself and thought to drink bleach but did not. Currently denies suicidal ideation/intent/plan, homicidal ideation, A/V hallucinations, delusions. Patient denies any physical pain, SOB, cough, chest pain, fever, or chills.

Plan:

1. COVID Positive:
   1. Droplet and contact and eye protection, Monitor vitals q4h.
   2. Currently: Patient is asymptomatic, no SOB, Cough. Temp 98.6 F and SpO2:

      99%

   3. PRN Tylenol tab 650 mg
   4. Advised patient to practice hand hygiene, use mask, and asked to practice social

      isolation.

2. Psychotic and depressive symptoms:

o Risperidone 1 mg PO, BID
o Administration of PRN medications: Lorazepam 2mg PO for anxiety, Haloperidol

5 mg oral for agitation.
o Psychologist: Provide individual therapy.
o Social worker: Discuss discharge and outpatient treatment options. o Elopement precautions: monitor q 30 mins

3. Benztropine (Cogentin) tab 0.5 mg BID for mild EPS.
4. Benadryl 50 mg PO PRN for sleep