Sonam Bhandari, Date: 03/04/2021

Elmhurst Hospital – Inpatient Psychiatry

 

Identifying Data: 

Name: RC

Date of Birth: XX/XX/1957 (63-year-old)

Race: Chinese

Sex: Male

Address: Queens, NY

Date & Time: February 12^th, 2021, 11:00 am

Location: Elmhurst Hospital, Elmhurst, Queens NY

Religion: Protestant

Source of Information: Self and chart review

Reliability: Somewhile unreliable

 

Chief Complaint: Mr. RC was brought in by EMS activated by his social worker after failure to contact over several days.

 

Mr. RC is a 63-year-old single unemployed Asian American male with Past medical history of DM, HTN, HDL and Past psychiatric history of schizophrenia, admitted to inpatient psychiatry unit B-9 from CPEP for stabilization. Patient test positive for COVID-19 on 02/11/21. Patient was brought in by EMS, which was activated by his social worker, after failure to contact him over several days. Upon entering his apartment, EMS found it to be unkempt and malodorous. His history is significant for previous hospital admissions to the psychiatric department. His current visit is attributed to noncompliance to his outpatient medications (Risperdal and Cogentin.) After last admission on 10/29/2019. In CPEP patient was observed laughing inappropriately and wanted to be addressed as ‘Dr. C”. He denied any psychiatric history.

 

During evaluation, the patient had poor insight regarding his illness and hospitalization.  He presented with delusions of grandeur, and the need to be addressed as “Dr. C.” He went on to mention that he has a MD/PhD from Cornell, Harvard, Stony brook and so on, and that he has been published many times and was preoccupied with the credentialing of the treatment team. He also attributes his unkempt apartment to the CIA, who happen to be working with his landlord. He had mumbled speech at times with low volume. He is also seen pacing in the hallway, laughing and talking to himself.

 

He denies any auditory or visual hallucinations, depressed mood, referential thinking, or suicidal ideation/ intent or plan.

 

Past Medical History: DM, HTN, HDL

 

Past Psychiatric History: Schizophrenia

 

Past Surgical History: No past surgical history

 

Allergies: No known food or drug allergies

 

FAMILY HX: Parents – alive, no siblings. unable to get further information.

 

Social history: Mr. C is a single Chinese American man who lives by himself. He is unemployed. He is isolated and does not have any friends and has no contact with this family. He states he sleeps about 6-7 hours a night and eats well. Denies use of alcohol or drugs. When asked about what he does he states he is a doctor with multiple publications and keeps busy doing his research.

 

REVIEW OF SYSTEM:

General –Denies fever or chills, night sweats, fatigue, or changes in weight.

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

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.

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

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

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

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

Gastrointestinal system –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, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength change in cognition /memory, or weakness.

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

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.

 

Mental Status Exam: 

General

1. Appearance: Mr. C is a tall Chinese American man with graying black hair. He is dressed in the hospital gown, is well groomed. Does not seem to be in any acute distress.
2. Behavior and psychomotor Activity: Mr. C did not show ant psychomotor agitation or retardation.
3. Attitude toward examiner: Mr. C is superficially cooperative and preoccupied with the credentials of all members of the healthcare team.

Sensorium and Cognition

1. Alertness and Consciousness: Mr. C is alert and able to answer questions throughout the interview with redirection.
2. Orientation: Mr. C was oriented to person, place and time.
3. Concentration and Attention: Mr. C had poor concentration, and attention. Had to be redirected frequently.
4. Capacity to read and write Mr. C had fair reading ability was unable to assess writing ability.
5. Abstract thinking: unable to assess abstract thinking.
6. Memory: Mr. C had poor memory; he was unable to recount incident leading to his hospitalization.
7. Fund of Information and Knowledge: Mr. RC has good fund of information and knowledge.

Mood and Affect:

1. Mood: C’s states that he is “feeling fine”
2. Affect: Mr. C’s is euthymic, congruent to his mood.
3. Appropriateness: Mr. C’s mood and affect were consistent with the topics discussed. He made inappropriate comments which he said were jokes. He did not express labile emotions, angry outbursts, or uncontrollable crying.

Motor:

1. Speech: Mr. C speaks in a normal rate and regular rhythm. However, at times his volume is soft and mumbled.
2. Eye Contact: Mr. C has fair eye contact.
3. Body movements: Mr. C had no extremity tremors or facial tics. He has a steady gait.

Reasoning and Control:

1. Impulse control: Mr. C’s impulse control was satisfactory. He did not have suicidal or homicidal urges.
2. Judgement: Mr. C has delusions of grandeur and paranoia. He denies auditory/visual hallucination.
3. Insight: Mr. C has poor insight on his illness and hospitalization.

 

VITAL SIGNS: 

BP: 121/66

PULSE: 82

RR: 18 bpm

Temp: 97.6 F

SpO2: 98%

 

PHYSICAL EXAM:

General appearance: Alert, cooperative, no distress, appears stated age

Lungs: clear to auscultation bilaterally, respirations unlabored.

Chest wall: no tenderness or deformity.

Heart: regular rate and rhythm, s1 and s2 normal, no murmur, rub or gallop.

Abdomen: soft, nontender, bowel sounds active all four quadrants.

Pulses: 2+ and symmetric all extremities

Lymph nodes: cervical, supraclavicular, and axillary nodes normal

Neurologic: CNII-XII intact. Normal strength, sensation and reflexes throughout.

 

Assessment: 63-year-old single male with Past psychiatric history of schizophrenia and Past medical history of DM, HTN, HDL admitted to inpatient psychiatry unit B-9 with psychiatric decompensation secondary to noncompliance to medication. Patient has delusions of grandeur and paranoia. He has poor insight and has poor recollection of events leading to hospitalization. He denies suicidal ideation, hallucinations, depressed mood, or referential thinking. Pt is COVID-19 positive. Patient denies any physical pain, SOB, cough, chest pain, fever, or chills.

 

Differential diagnosis:

• Schizophrenia: Patient has a PPH of schizophrenia. This is most likely psychiatric decompensation secondary to medication noncompliance. Patient has significantly impaired functioning and presents with delusions of grandeur, self-isolation, and very poor insight to his illness.
• Brief psychotic disorder: less likely since patients with brief psychotic disorder present with one or more of the following symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior between 1 day to 1 month. If this was patient’s first presentation it would be more likely.
• Delusional Disorder: Patient has non bizarre delusions however it is unlikely to be delusional disorder since his daily functioning is significantly impaired and given his past psychiatric history of schizophrenia.
• MDD with psychotic features: Unlikely, but patient had been self-isolating, not taking care of himself and his apartment and has delusions of grandeur. He stopped taking his medications. Indicating loss of interest, however patient denies any depressed mood, change in appetite, changes in sleep, fatigue, recurrent thoughts of death or suicide.

 

Plan:

1. COVID Positive:
   1. Droplet and contact and eye protection, Monitor vitals q4h.
   2. Currently: Patient is asymptomatic, no SOB, Cough. Temp 97.6 F and SpO2: 98%
   3. PRN Tylenol tab 650 mg
2. Stabilization of Psychiatric decompensation:

• • Risperidone 1 mg PO, BID
  • Administration of PRN medications: Lorazepam 1mg PO BID, Risperidone disintegrating tablet 0.5 mg PO Q6H
  • Psychologist: Provide individual therapy.
  • Social worker: Discuss discharge and outpatient treatment options.

1. DM:

• Start Lantus insulin 20 units subcutaneous nightly, fingerstick QID with Lispro insulin sliding scale coverage, Janumet 50-1000 mg po BID. HbA1c 15.8

4. HTN:

• Atenolol 50 mg po daily, BP 121/66, HR 82

5. HLD:
   • Atorvastatin 20 mg po nightly

1. DVT prophylaxis:

• Lovenox 40 mg SC, daily