Sonam Bhandari, Date: 03/04/2021

Elmhurst Hospital – Inpatient Psychiatry

 

Identifying Information:

Name: JR

Date of Birth: XX/XX/2002 (18-year-old)

Race: Hispanic

Sex: Female

Address: Queens, NY

Date & Time: February 26, 2021, 4:30 pm

Location: Elmhurst Hospital, Elmhurst, Queens NY

Source of Information: Self and chart review

Reliability: Reliable

 

Chief Complaint: Mrs.  JR was admitted from her OBGYN appointment for expressing Suicidal ideation and action.

Mrs.  JR is an 18-year-old married Hispanic female, G2P1001, 12 wks. 4d pregnant, living with her husband and brother-in-law. Past medical history of frequent UTI’s and Pyelonephritis (last 02/04/21), and past psychiatric history of Depression and Suicidal Ideation, recently admitted to inpatient psych for Suicidal ideation and attempt by wrapping a blet around her neck.

Mrs.  R stated that her depressive symptoms had been worsening over the last month and identified feeling overwhelmed with parenting responsibilities. She expressed feelings of hopelessness, loss of interest in cleaning, cooking, art, crying every day, feeling tired, low self-esteem, trouble concentrating and feeling like a failure over the last month for which is scheduled an outpatient intake appointment at Elmhurst on the 24^th which she missed as “no one was there to take care of my baby.”

She described the suicide attempt as ‘impulsive-the thought hit like a bucket of ice water’ and provided details of how she had been experiencing anxiety attacks (e.g., difficulty breathing, tearfulness, negative thoughts) throughout the day. She reported that her husband came home from work and relieved her from childcare duties. She then went on to engaged in the attempt when left alone in her room. She reported that her husband found her and reported that her face had begun to change color due to lack of oxygen after which her husband wanted to activate 911 and did not at her request. She reported that she feared punishment/consequences. She reported that she is concerned about her partner abandoning her even though he has expressed commitment to her and their family. She reports that this stems from her parents’ divorce when she was in middle school. She is estranged from her mother and seldom talks to her father who is in Puerto Rico. She described limited social support outside of her husband’s family.

 

She denied current suicidal ideation, Homicidal Ideation, auditory/visual hallucination. Patient States urinary discharge and burning while peeing. Patient is COVID-19 positive otherwise in no acute distress. Denies shortness of breath, cough, chest pain, fever, night sweats, or chills.

 

 

Past Medical History:

Pyelonephritis: 2/04/21

 

Past Psychiatric History:

Depression – 02/2018

 

Past Surgical History:

Denies any surgeries

Denies past injuries or blood transfusions.

 

Medications:

Keflex 250 mg – pyelonephritis

Prenatal vitamins-folic acid-iron 1-tab po daily: pregnancy

 

Allergies:

Macrobid [Nitrofurantoin] – itching and rash

Strawberry – itchy

 

Family History:

Patient states history of possible depression in mom, aunt, and grandmother.

Mother – Alive, possible history of depression.

Father – Alive and well.

Sister: alive and well.

 

Social History: 

Patient is married pregnant female, who resides with her 9-month-old daughter, husband and brother-in-law. She is a stay-at-home mom. Admits to difficulty staying sleeping over the last month she sleeps a total of 8 interrupted hours. She has decreased appetite and states she eats “whatever is around” since she does not feel like cooking anymore.  She denies any current or past use of smoking and drinking. She denied use of illicit drugs.

Review of Systems:

Review of Systems

Constitutional: Negative for chills and fever.

HENT: Negative for ear discharge, ear pain and sore throat.

Eyes: Negative for photophobia, pain, discharge, redness, itching and visual disturbance.

Respiratory: Negative for cough, choking, chest tightness, shortness of breath, wheezing and stridor.

Cardiovascular: Negative for chest pain, palpitations and leg swelling.

Gastrointestinal: Negative for abdominal distention, abdominal pain, blood in stool, diarrhea, nausea and vomiting.

Genitourinary: Negative for dysuria, hematuria; +vaginal discharge, burning and itching, +hx of frequent UTI and pyelonephritis

Musculoskeletal: Negative for arthralgias, gait problem, joint swelling, myalgias, neck pain and neck stiffness.

Skin: Negative for color change, pallor, rash and wound.

Neurological: Negative for dizziness, syncope, tremors, seizures, facial asymmetry, speech difficulty, weakness, numbness and headaches.

Infectious Disease:  +COVID-19

 

Mental Status Exam: 

General

1. Appearance: Slender young female dressed in hospital gown. Appears her stated age.
2. Behavior and psychomotor Activity: Did not show ant psychomotor agitation or retardation.
3. Attitude toward examiner: Is cooperative throughout the interview. Is pleasant and able to create rapport.

Sensorium and Cognition

1. Alertness and Consciousness: Was alert throughout the interview.
2. Orientation: Is oriented to person, place, date and time.
3. Concentration and Attention: Patient had good concentration throughout the interview and answered all questions thoroughly.
4. Capacity to read and write: Patient has poor ability to write and fair ability read in English.
5. Abstract thinking: Patient can compare and contrast similarities and differences in objects.
6. Memory: Patient remote and recent memory were both intact.
7. Fund of Information and Knowledge: Patient demonstrates average intelligence.

Mood and Affect:

1. Mood: Patient states feeling overwhelmed, depressed and hopeless but she is glad that her suicide attempt was unsuccessful.
2. Affect: Patient affect was sad, congruent to her mood.
3. Appropriateness: Patient mood and affect both reflected her depressed mood.

Motor:

1. Speech: Patient spoke fast rate and regular rhythm.
2. Eye Contact: Patient made good eye contact while speaking and listening.
3. Body movements: Patient has a steady gait, no extremity tremors or facial tics. Her movements were purposeful.

Reasoning and Control:

1. Impulse control: Recent and past Suicidal attempt/ideation. Currently denies Suicidal or homicidal ideation.
2. Judgement: Currently compliant with medication/treatment. Denies Auditory or visual hallucinations, paranoia, or delusions.
3. Insight: Patient has good insight into her psychiatric illness, she states that she needs help and is open to taking medication.

 

VITAL SIGNS: 

BP: 125/60 (right arm)

PULSE: 87

RR: 16 bpm

Height: 5’4”

Weight: 162.6lbs

BMI: 23 kg/m²

Temp: 98 F

SpO2: 99%

 

 

Physical Exam

Constitutional: Patient is oriented to person, place, and time. Patient appears well-developed and well-nourished. No distress.

HENT:

Head: Normocephalic and atraumatic.

Right Ear: External ear unremarkable.

Left Ear: External ear unremarkable.

Nose: Nose unremarkable.

Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate.

Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.

Neck: Normal range of motion. Neck supple. No JVD present. No tracheal deviation present. No thyromegaly present.

Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses.  Exam reveals no gallop and no friction rub. No murmur heard.

Pulmonary/Chest: Effort normal and breath sounds normal. No stridor. No respiratory distress. Patient has no wheezes. Patient has no rales. Patient exhibits no tenderness.

Abdominal: Soft. Bowel sounds are normal. Patient exhibits no distension and no mass. There is no tenderness. There is no rebound and no guarding.

Genitourinary: REFUSED

Musculoskeletal: Normal range of motion. Patient exhibits no edema, tenderness or deformity.

Lymphadenopathy:

Patient has no cervical adenopathy.

Neurological: Patient is alert and oriented to person, place, and time. No cranial nerve deficit. Patient exhibits normal muscle tone. Coordination normal.

Skin: Skin is warm. No rash noted. Patient is not diaphoretic. No erythema. No pallor. No ulcers. No wounds. No petechiae nor purpura.  Exposed skin is WNL

Assessment:

Mrs.  JR is an 18-year-old married Hispanic female, G2P1001 that’s 12 wks. 4d pregnant, living with her husband and brother-in-law with Past medical history of frequent UTI’s and Pyelonephritis (last 02/04/21), and past psychiatric history of Depression and Suicidal Ideation, recently admitted to inpatient psych for Suicidal ideation and attempt by wrapping a blet around her neck. Patient states feeling worsening depression over the last month with an ‘impulsive-the thought hit like a bucket of ice water’ suicide attempt. Currently denies SI/HI, and A/V hallucinations. She is covid-19 positive. States urinary discharge and burning while peeing. Denies shortness of breath, cough, chest pain, fever, night sweats, or chills.

 

Differential diagnosis:

MDD with peripartum onset: Patient meets criteria for MDD within 12 months of giving birth. Patient has a past psychiatric history of depression, over the past month she has had little interest or pleasure in doing things, feels hopeless, trouble staying asleep, has crying spells, poor appetite, trouble concentrating, feels like she is moving or speaking slowly for most days.

 

Recurrent Major depressive disorder: Patient has a past psychiatric history of depression, over the past month she has had little interest or pleasure in doing things, feels hopeless, trouble staying asleep, has crying spells, poor appetite, trouble concentrating, feels like she is moving or speaking slowly for most days. This is congruent with the diagnosis of MDD. Patient has had psychosocial events that increase risk factor for developing MDD.

 

Persistent depressive disorder: Patients present with depressed mood nearly every day for > 2 years associated with at least 2 of changes in sleep, appetite, low energy, low self-esteem, poor concentration, hopelessness etc. While the patient has had depression for more than 4 years she does not state depressive symptoms nearly every day for past 2 years.

 

Bipolar II disorder: is diagnosed in patients with Bipolar disorder if they have a history of recurrent major depressive disorder with hypomania. However, it is harder to identify hypomania and patient did not state any distractibility, irritable mood, grandiosity, flight of ideas, agitation, or pressured speech. These symptoms may present at a later date, so it is important to have patient follow up with outpatient treatment.

 

Plan:

1. Suicide risk
   1. Routine observation
2. Depressive symptoms:

• • Fluoxetine 10 mg PO
  • Psychologist: Provide individual therapy.
  • Social worker: Discuss discharge and outpatient treatment options.
  • Elopement precautions: monitor q 30 mins

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. Advised patient to practice hand hygiene, use mask, and asked to practice social isolation.

4. Vaginal Candidiasis
   1. Follow up with OB/Gyn: terconazole 0.8% vaginal cream for 3 days.