In my psych clinical correlations class, I was given the opportunity to create my own H&P case of a fictional psych patient. I had a lot of fun creating the case and being able to act as the patient as my 2 other classmates interviewed me. This is what I came up with……

 

Markenzie Jean-Baptiste

4/08/2020

Rotation#3: Psychology

History and Physical

 

Identifying Data:

Name: BS

Age: 20

Nationality: African American

Date & Time: 4/08/2020 @ 4:45pm

Location: Queens Hospital Psych Emergency Department

Source of Referral: Police officer, mother

Source of Information: Self  and mother- both reliable

Mode of Transport: ambulatory

 

Chief Complaint: “I got into a fight at school today x 2 hours ago”

History of Present Illness:

Ms. B.S. is a 20 y/o AA female, presents to Psych ED today with contusion to the LT side of face s/p getting into a fight at school with another girl x 2 hours ago. PT reports that the girl she fought stole her boyfriend from her about 1 week ago and when she saw her today, she approached her and they began to fight. PT reports that she was punched on the LT side of her face but denies any other injuries from the fight. Pt reports that she started having feelings of depression and problems controlling her mood about 2 months ago. She reports going days without sleeping, began having trouble concentrating in school and stopped going to classes regularly in the past 2 months. Reports that she has been going to dance parties more frequently and would have 3-4 alcoholic drinks on Saturday nights usually. Also reports that she started having unprotected sexual relationships with 3 different men in the past 2 months. PT reports that she has been going on shopping spree, spending her money on new outfits for when she goes out to party, and this has caused her to have high credit card balance. PT reports that all of this has had her feeling more depressed and she thinks that her mother is ashamed of her. Patients mother reports that pt’s mood has been out of control in the past 2 months and her emotions have been “up and down. Pt’s mother reports that she took her daughter to see a psychiatrist at an Urgent Care x 1 month ago after she got into a fight with a girl at school and was yelling at other students and teachers. Pt’s mother reports that pt was diagnosed with Bipolar disorder and prescribed lithium 300mg TID. PT reports that she took lithium for 1 week in which she had less changes in her mood, was less depressed and slept better during this time but she lost the medication 3 weeks ago and has not taken it since. Pt’s mother reports that prior to this episode 2 months ago, pt had seemed depressed sometimes, but she did not know that pt had some of these behavioral problems. PT’s mother reports that pt’s older sister had similar mood swings but never was evaluated by a psychiatrist. PT denies suicidal or homicidal thoughts, auditory or visual hallucination, or paranoia ideations. Denies headache, syncope, LOC, vision changes, chest pain, SOB, fever, chills.

 

Past Medical History:

Present illness: Bipolar Disorder w/ manic episode

Past illness:  none

Hospitalizations: none

Medications:

Lithium 300 mg tablet, 1 tab TID- last dose was 3 weeks ago.

Denies taking any other medications.

Allergies:

Denies drug allergies, food allergies or environmental allergies.

Past Surgical History:

Denies injuries, past surgeries and transfusions.

Immunizations

Flu vaccine yearly, all other childhood immunizations are up to Date

Family History:

Mother: 44, alive- denies hx HTN or diabetes

Father: 48, alive- hx denies hx HTN or diabetes

Sister: 26, alive and well

Brother: 16, alive and well

 

Social History:

Ms. BS is a 20 y/o AA female who lives at home with her mother and younger brother on the 3^rd floor of a 5th floor apartment building. PT attends York College and is studying business administration with plans of opening up her own hair salon in the future. PT’s mother and father have been divorced for about 6 years. Pt’s mother reports that pt’s sister who is married has had mood swings as well but never was evaluated by a psychiatrist.

Habits:  PT admits to drinking alcohol socially- 3-4 alcoholic drinks weekly at parties. Denies ever smoking cigarettes. Denies ever smoking marijuana or using illicit drugs.

Marital History: single

Sexual History: PT reports that she started having unprotected sexual relationships with 3 different men in the past 2 months. Denies any hx of known STD. Does not recall her last STD testing.

Diet: Reports that she consumes a balanced diet.

Sleep: Reports that she has days where she gets 5 hours of sleep a night but also times when she does not sleep for 1-2 days at a time. Reports that she has had difficulty falling asleep and this started about 2 months ago.

Exercise:  Reports that she goes to the gym 1-2 times a week but this is not consistent.

 

Review of Symptoms:

General: Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, recent weight gain or loss

Skin, hair, nails: (+) contusion to LT side of face over cheek Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head: Denies headache, vertigo, head trauma, unconsciousness, coma, fracture

Eyes:Denies visual disturbances, fatigue, lacrimation, photophobia, pruritus,

Ears: Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses: Denies discharge, epistaxis, obstruction

Mouth and throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, last dental exam

Neck: Denies localized swelling/lumps, stiffness/decreased range of motion

Pulmonary: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

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

Gastrointestinal: Denies abdominal pain, vomiting, diarrhea, changes in appetite, dysphagia, pyrosis, flatulence, eructation, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, pain in flank

Genitourinary: Denies urinary frequency/urgency, incontinence, dysuria, nocturia, oliguria, polyuria, impotence, anorgasmia, sexually transmitted infections, contraception

Musculoskeletal: Denies muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular: Denies intermittent claudication, coldness, trophic changes, varicose veins, peripheral edema, color changes

Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE

Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous System: Denies seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)

Psychiatric: (+)  depression/sadness, Denies suicidal ideation, anxiety, obsessive/compulsive disorder, (+) history of seeing mental health professional

Physical Exam:

Vitals:

T:97.9F

HR: 72 beats/min

RR:18 breath/min,

BP: 128/82

SP02: 98%

Ht: 66 inches

Wt: 150

BMI: 24.2

 

General: A/O x 4, Pt is wearing handcuffs and appears agitated but cooperative. PT is talking excessively at times but is coherent. PT is well appearing and groomed.

Skin: warm and moist, good turgor, non-icteric, no lesions or rashes

Nails: cap refill <2 secs throughout,

Head:  normocephalic, (+) contusion noted to the LT side of face over the LT maxilla, No other obvious abnormality

Eyes: PERRLA, conjunctiva and cornea clear. No scleral icterus

Nose: Nares normal, septum midline, mucosa normal.

Throat: lips, mucosa and tongue are normal; missing upper and lower teeth, front tooth is loose.

Lungs: Clear to auscultation bilaterally, respirations unlabored, no wheezes/ rales/rhonchi

Cardiovascular: Regular rate and rhythm, S1 and S2 normal, no murmur, rubs or gallop

Abdomen: Soft, non- tender, no guarding or rebound tenderness in all 4 quadrants. No masses. No rigidity.

Extremities: Normal in color, size and temp. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted b/l.

Neuro: Pt alert and oriented to time, place and date. Receptive and expressive abilities intact. Full ROM of extremities. Strength 5/5  bilaterally throughout all extremities.CN 2-12 Intact. Reflexes: 2+ throughout.

 

Mental Status Exam

Appearance and Behavior:PT is alert and oriented x 3, well appearing and groomed. Pt appears agitated and wearing handcuffs but has normal gait..No tics or abnormal movements PT dressed appropriate to age and weather. No dyskinesias, stares or mask-like facies.

Speech and language:PT is coherent. Able to name items shown, categorize them, follow command. Speech is expressive but sometimes rapid. Overall good tone and fluency.

Mood:Pt denies any suicide ideation. Reports that she has been having difficulty controlling her anger recently. Reports that she has been feeling down and depressed recently because of everything she is dealing with. Denies any changes in her interest in doing things.

Thought Processes/Content:No hallucinations, delusions, phobias.

Insight and Judgement:Patient able to express her problems. Able to understand her diagnoses of bipolar disorder. When asked why she stopped taking the medication, PT stated that she lost it but if was given another prescription, she would try to take since it helped her feel better previously.

Memory and Attention:PT is alert and oriented to name, date, time and location, has good recall, good remote and recent memory.

Higher Cognitive Functions:PT has good cognitive functioning. PT is able to name presidents of large cities, perform simple addition, subtraction, multiplication. Has good abstract thinking, understand similarities between words. Good constructional and new learning ability.

 

Assessment:

20 y/o AA female, presents to Psych ED with contusion to the LT side of face s/p getting into a fight at school with another girl x 2 hours ago. Pt has hx of feeling depressed, insomnia and problems controlling her mood x 2 months. On physical exam, pt shows no sign of cognitive impairment but is displaying signs of mania, agitation and impaired judgment with hx of fighting, shopping sprees and unprotected sexual relationships with multiple partners. PT was evaluated by a psychiatrist Dr. Z x 1 month ago who dx pt with Bipolar Disorder after pt had a manic episode and fought another girl at school the same day. PT was started on lithium 300 mg TID. PT reported that she had some symptom improvement for 1 week but her symptoms worsened after she stopped taking the medication because she lost the bottle.

Plan:

Bipolar disorder:

• Run urine HCG
• If urine HCG is negative, start pt on Lithium 300 mg TID and monitor pt in psych ED for signs of improvement (decreased agitation and fluctuations in mood). Can also prescribe Risperidone if minimal improvement with lithium.
• Blood work: CBC, CMP, TSH/thyroid function, urine/blood tox, lithium level
• Monitor serum concentration of lithium- therapeutic range (6 and 1.2 milliequivalents per liter (mEq/L).
• Once pt is stable, refer pt to her psychiatrist/establish care with new psychiatrist for further pharmacological management and psychotherapy.

Insomnia

• Talk to patient about healthy sleeping patterns, practices, suggest melatonin. Refer pt to her psychiatrist for further management.

Alcohol use

• Counsel patient on safe alcohol use.

 

Differential Diagnoses:

1. Bipolar 1 disorder: pt has hx of 2 manic episodes, mood fluctuation, poor judgment, hyper-sexuality, depression, insomnia, 1st degree relative with similar hx of possible bipolar disorder, family member with similar hx.
2. Bipolar 2 disorder: hx of manic episode- abnormal/persistent elevated mood, partying, spending money, depression, mood swing. No psychotic features. More likely bipolar 1 since pt has had a previous manic episode and 1^st degree relative.
3. Depression Disorder- female, onset during 20’s, hx of depressed mood, insomnia, feeling that her mother is ashamed of her, recent breakup, hx of financial problems.
4. Borderline Personality Disorder: hx of unstable, unpredictable mood and affect since pt did get into a fight, poor spending. Hx of substance abuse and increased spending. Fights at school. More hx is needed to assess this personality disorder.
5. Histrionic Personality Disorder: Possible attention seeking with purchasing new outfits for parties. Hx of fights at school, yelling at teachers. More hx is needed to assess this personality disorder.

 

 

Medication options for Bipolar 1 Disorder

Mood stabilizers:

• Lithium( decreased suicide risk), Valproic acid (Depakene, Depakote), Carbamazepine (Tegretol)

2^nd generation( atypical antipsychotic)

Risperidone, Quetiapine Olanzapine or Ziprasidone

• Effective as monotherapy or as adjunctive therapy to mood stabilizers like lithium.

For acute mania

Antipsychotics (Risperidone or Olanzapine > Haloperidol)

Mood stabilizer( Lithium or Valproic acid)