CC – As per patient’s husband patient was having “Aggressive and threatening behavior” X 2 hours ago
HPI – 26 y/o female with history of psychosis who was brought in by EMS activated by her husband for agitation and erratic behavior. Both husband and patient have not been living in the same apartment for the past month because husband stated he needed space from his wife. Today patient’s husband came to their apartment along with patient’s father and saw the patient with another unidentified man in their living room. The husband noticed a baggy with some kind of white substance in it. The husband was trying to get the man to leave the apartment and that is when the patient started acting erratically, pushing people around and then throwing herself to the ground.
Patients mother states patient went to Hawaii in early May 2024, had a manic episode with poor sleep and was in hospital for few days. In early June 2024, patient went to Dallas to find a new apartment there and had the same manic episode there. Both times patient’s father had to fly to where the patient was and get her back home. Patient’s mother said that the patient was recently on a spending spree and spent thousands of dollars. Patient’s mother also admits patient is constantly in and out of house most of the time and barely sleeps.
Patient is adamant that nothing happened today and everyone is lying. She states is in the process of divorcing her husband and has plans of moving to Dallas to find a new apartment to get away from him and her father who she says is overbearing. Patient denies any suicidal ideations, homicidal ideations, auditory hallucinations, or visual hallucinations. Patient admits to having a few alcohol drinks weekly with friends, as well as smoking cannabis a few times a week but denies any illicit drug use.
Patient was diagnosed with bipolar disorder in 2022, and was given Risperidone but the patient did not like how she felt and stopped taking the medication.
HISTORY
Past Medical History: No past medical history
Past Psychiatry History: Psychosis
Past Hospitalizations: January 2022 – brought to QHC CPEP accompanied with husband after exhibiting bizarre behavior, hallucinations, and patient has not slept in five days
Medications: Not currently on any medications
Past Surgical History: No past surgical history
Allergies: No known drug/environmental/food allergies
Family History:
Mother – alive and well
Father – alive and well
Social History
Living Situation: Lives by herself away from her husband
Highest level of Education: Bachelor of Arts in Science from Cornell University
Employment: Currently unemployed, but used to work for Etsy as a talent/project manager and getting severance payments from them because of a dispute between her and the company
Relationship Status: Married, but in the process of divorcing her husband
Sleep: 2-3 hours a night
Alcohol: A couple of times a week with friends
Tobacco: 2-3 times weekly
Illicit Drug Use: denies use
Past arrest/incarceration history: none
VITALS
BP: 117/77 (RA, sitting)
Temp: 98.3 F
Pulse: 91 beats per minute
RR: 18, unlabored
SpO2: 100% on room air
Weight: 185 lb
REVIEW OF SYSTEMS
General – Denies weakness/fatigue, fever.
Skin, hair, nails – Denies rash, pruritus, excessive sweating.
Head – Denies headache, dizziness, denies head trauma.
Eyes – Denies visual changes.
Nose/Sinuses – Denies congestion.
Mouth/Throat – Denies sore throat, cough.
Neck – Denies pain.
Pulmonary System – Denies SOB, coughing, DOE.
Cardiovascular System – Denies chest pain, palpitations.
Gastrointestinal System – Denies loss of appetite, nausea, vomiting, changes in stool.
Genitourinary System – Denies pain.
Nervous – Denies dizziness, gait disturbances, sensory disturbances, paresthesia.
Musculoskeletal system – Denies pain.
Endocrine system – Denies excessive hunger/thirst.
Psychiatric – Denies past suicidal attempts, current suicidal ideations, current visual or auditory hallucinations, homicidal ideations, or homicidal attempts.
PHYSICAL
Patient is a 26-year-old female who appears her stated age. Patient is alert and oriented to person, place, and time, well developed, in no acute distress.
MENTAL STATUS EXAM
General
Appearance: Patient is casually groomed with good eye contact. Appears anxious in her hospital gown that overlays her normal clothing. Normal hygiene.
Behavior & Psychomotor Activity: No apparent tics, tremors, or fasciculations.
Attitude Toward Examiner: Cooperative, receptive, and engaging in the conversation.
Sensorium & Cognition
Alertness & consciousness: Patient was conscious and alert throughout the interview.
Orientation: Patient was oriented to the date, place, and time of the interview.
Concentration & Attention: Displayed satisfactory attention, was alert during the entire interview.
Capacity to Read & Write: Patient was able to properly sign name and read.
Abstract Thinking: Proper ability to abstract. Average ability to use deductive reasoning.
Memory: Patient’s remote and recent memory appear intact.
Fund of Information & Knowledge: Patient’s intellectual performance consistent with level of education.
Mood and Affect
Mood: Anxious
Affect: Normal intensity
Appropriateness: Her mood and affect were congruent with discussed topics. She experienced the same emotion throughout the entirety of the conversation.
Motor
Speech: Hyper verbal
Eye contact: Consistent eye contact throughout the conversation.
Body movements: Body posture and movement is appropriate.
Reasoning and Control
Impulse Control: Impaired
Judgment: Impaired
Insight: Impaired
RISK ASSESSMENT
Wish to be dead – Have you wished you were dead or wished you could go to sleep and not wake up? No
Suicidal thoughts – Have you actually had any thoughts of killing yourself? No
—If YES to 2, ask questions 3, 4, 5 and 6. If NO to 2, go directly to question 6—
Suicidal thoughts with method – Have you been thinking about how you might kill
yourself? No
Suicidal intent – Have you had these thoughts and had some intention of acting on
them or do you have some intention of acting on them after you leave the hospital? No
Suicide Intent – Have you started to work out or worked the details of how to kill
yourself either for a while you were here in the hospital or for after you leave the
hospital? Do you intend to carry out this plan? – No
Suicide behavior – While you were here in the hospital, have you done anything,
started to do anything, or prepared to do anything to end your life? No
Risk to self? No
Risk to others? No
DIFFERENTIAL DIAGNOSIS:
Bipolar 1 disorder:
This differential is the highest on the list. The patient has a decreased need for sleep (generally 2-3 hours a night), has spending sprees, and engages in promiscuous situations with individuals they might not know. The patient has very good self-confidence and seems like they are distracted with anxious energy attached to them. The patient had solo flights to both Hawaii and Dallas, TX, lost her phone on both occasions and had to get her parents to bring her back home because she had a manic episode in both airports.
Drug-induced Psychosis:
The patient admits to smoking cannabis and drinking alcohol weekly and has a history of psychosis a couple of years back leading to drug-induced psychosis also being very high on the differential list. Although this patient has impaired thoughts and judgement, she is not having any hallucinations or delusions commonly seen in patients with drug-induced psychosis.
Borderline Personality Disorder:
The patient’s unprofessional behavior at her home pushing her family around and then falling to the floor, her unstable relationship with her husband and father, and the patient’s impulse shopping sprees mentioned by her mother may suggest an underlying personality disorder like borderline personality disorder which could account for her impulsive and erratic behaviors.
Schizoaffective disorder – bipolar type:
The patient’s conflict with her family and her spouse, her issue with her employment, cannabis/alcohol use might all be pointing toward a diagnosis of schizoaffective disorder with bipolar traits. There is a lack of hallucinations and the patient’s speech is not disorganized.
ASSESSMENT
A 26-year-old female with a past psychiatric history of psychosis was brought in by EMS activated by her husband for aggressive and threatening behaviors. Currently, patient is not a threat to herself or others. History and psychiatric evaluation demonstrate a diagnosis consistent with Bipolar 1 disorder.
Diagnosis – Bipolar 1 disorder
Disposition – Admit to inpatient psychiatric unit
PLAN
Routine Labs CBC, CMP, UA, UTox to rule out possible substance induced psychosis
Q15 minutes observation
Start Olanzapine 10 mg at bedtime and Depakote 250 mg twice daily
Have patient complete group work including relaxation, communication, and creative arts skills
