I was placed in Queens Hospital Center for my Psychiatry rotation for 4 weeks. There I was in the comprehensive psychiatric emergency program for the entire duration of the rotation. It was a very interesting and rewarding rotation. I learned how to manage a wide variety of psychiatric illnesses. The most common complaints were suicidal ideation, and aggressive behavior. I learned a lot on managing patients who were acutely decompensating.

1. History and Physical Write up 

Taiba Shah

Queens Hospital Center

 

Identifying Data:

Full Name: Ms. A.M.

Address: 55-55 13th street Jamaica Queens N.Y.

DOB: 02/ 17/1997

Date & Time: 08/30/2020

Location Psych- ER in QHC

Religion: Unknown

Source of information: Self

Source of referral: Mother

Mode of transport: FDNY EMS

 

Chief Complaint: “I had an argument with my mother”

HPI: 23-year-old African American female, unemployed on social security income, domiciled with mother (Priscilla, 929-555-7873 ), with past psychiatric history of Schizophrenia (diagnosed March 2019), Bipolar Disorder Type 1(diagnosed October 2018) and past medical history of DiGeorge Syndrome, brought in to CPEP by EMS, activated by mother, for reported agitation. The patient states she got into an argument with her mother after not being able to go outside. She states she was yelling, breaking things, and hit her mother, but says “I don’t remember everything” when asked for details. The patient is known to CPEP  with multiple visits for similar reasons, her with last discharge was on 08/14/2020. In her last visit with Dr. Qyumm, she was admitted to CPEP for physically attacking her mother because she believed her mother was stealing from her. The patient has also been admitted for a manic episode where she was not able to sleep for 5 days and had racing thoughts on 10/13/2019. She is currently following up with QHC Adult Outpatient Clinic under the care of a psychiatrist Dr. Samee. She is compliant on Vraylar 3mg daily, Cogentin 0.5 mg daily. Patient was on lithium 600 mg in addition to Vraylar and Cogentin, however, the lithium was discontinued on 08/14/2020 by Dr. Samee, as per note, “patient and mother reported controlled anger and improved outbursts and requested to discontinue Lithium”. Patient admits to occasional alcohol and marijuana use 1-2 times per week and denies any other illicit drug use, no recent use.

 

Collateral information was obtained from the mother. She reports the patient got agitated when the patient was told her SSI check did not come in yet. Her mother tried to explain to her the checks come in on the 1st of every month but the patient was becoming aggressive and did not listen. The patient was claiming the mother was taking her SSI checks. The mother states the patient was punching her in the stomach and when the mother tried to hug her and console her,  she could not be calmed down. There is a 3 y.o. at home (patient’s brother), and the mother worrying about the safety of her child, called EMS. Patient is requesting to be discharged to shelter, and says she does not want to go back to living with her mother. Patient currently denies suicidal ideations, homicidal ideations, visual hallucinations and auditory hallucinations, or intent to hurt self or others.

 

PAST MEDICAL

DiGeorge syndrome-

Bipolar Disorder Type 1- Diagnosed October 2018

Schizophrenia-Diagnosed March 2019

Substance use: Admits to marijuana use 1-2 times per week. Denies alcohol use, tobacco use, and other illicit drugs

 

SURGICAL HISTORY

Bioprosthetic pulmonic valve for pulmonary atresia in 11/09/2018 at Cornell

 

MEDICATIONS

Cariprazine (VRAYLAR) 6 MG Cap capsule, Take 1 capsule (6 mg total) by mouth daily.-last dose this morning

Benztropine (COGENTIN) 0.5 MG tablet, Take 1 tablet (0.5 mg total) by mouth nightly.- last dose last night

ASPIRIN 325 MG EC tablet, take 1 tablet by mouth every day- last dose last night

Metoprolol succinate er (TOPROL) 25 MG 24 hr tablet- Last dose last night

 

ALLERGIES

Denies any drug or food allergies

 

FAMILY HISTORY

Denies pertinent family history

 

SOCIAL HISTORY

Ms. A.M. is an African American female, who is single with no children, heterosexual, unemployed, domiciled with mother (Pricilla) and brother (3 years old). She has always been unemployed and collects SSI checks. She has no reports of sleep disturbances. She lives in NYCHA housing in Jamaica Queens. Her highest level of education is high school completion. She admits to marijuana use 1-2 times per week and denies alcohol use, tobacco, and other illicit drugs.

 

REVIEW OF SYSTEMS

General – Patient denies any changes in appetite, recent weight gain or weight loss

Skin – Denies self-inflicted wounds, intravenous drug use, or skin picking

Neurology – Patient denies headache, dizziness, loss of consciousness, history of head trauma, unsteady gait, and uncontrollable body movements

Psychiatric – The patient admits to getting aggravated at times especially with her mother and physically hits people and objects. She currently denies suicidal/homicidal ideations and visual/auditory hallucinations

 

PHYSICAL EXAM 

 

Vital signs

BP 105/72 (BP Location: Left arm, Patient Position: Sitting)  | Pulse 89  | Temp 98.8 °F (37.1 °C) (Oral)  | Resp 18 (unlabored)  | Ht 1.524 m (5′)  | Wt 65.8 kg (145 lb)  | SpO2 99% (room air)  | BMI 28.32 kg/m²

 

General                     

1. Appearance: Ms. A.M. is a medium height and overweight young African American female. She has no scars on her face or hands. Her hygiene was clean and she was well-groomed.
2. Behavior and Psychomotor Activity: Ms. A.M. had mild psychomotor slowing, displaying delayed verbal response time, and decreased motor activity.
3. Attitude Towards Examiner: Ms. A.M. cooperated with the examiner and did not display any hostility or aggression towards the examiner or other staff members. She established rapport within a few minutes.

Sensorium and Cognition

1. Alertness and Consciousness: Ms.A.M. was alert, and was conscious throughout the interview
2. Orientation: Ms.A.M. was oriented to the time of day, the place of the exam, and the date.
3. Concentration and Attention: Ms. A.M. demonstrated satisfactory attention during the interview and provided appropriate responses to questions.
4. Capacity to Read and Write: Ms. A.M. had satisfactory reading ability as shown by her writing down the mother’s name and contact information.

 

5. Abstract Thinking: Ms. A.M. is fair, she is able to clarify her thoughts. When asked What makes apples and oranges similar? She stated, “They are fruits.”
6. Memory: Ms. A.M. remote memory was intact, but recent memory about the details of her argument with her mother was mildly impaired.
7. Fund of Information and Knowledge: Ms.A.M. intellectual performance was marginal but consistent with her level of education (high school graduate)

 

Mood and Affect

1. Mood: Ms. A.M.’s dysphoric. She did not smile at all during the interview. When asked how she feels she stated “not good”
2. Affect: Ms. A.M.’s affect was flat.

3. Appropriateness: Ms. A.M’s mood and affect were inconsistent with the topics she discussed. She was expressionless discussing the argument with her mother. She did not exhibit labile emotions, angry outbursts, or uncontrollable crying.

 

Motor

Speech: Ms. A.M’s speech pattern was low volume and slow. Her speech was coherent and concise. She did not require any redirection.

Eye Contact: Ms. A.M. made adequate eye contact throughout the interview.

Body Movements: Ms. A.M had no extremity tremors or facial tics. She had a slow gait with decreased arm swing.

 

 

Reasoning and Control

1. Impulse Control: Ms. A.M. impulse control is currently satisfactory. She did not have suicidal or homicidal urges.

 

2. Judgment: Ms. A.M. currently admits to the paranoia that her mother is stealing from her is “trying to harm her”. She denies auditory or visual hallucinations.
3. Insight: Ms. A.M. had fair insight into her psychiatric condition, her current medications, and the need to be complainant with her medications. She did have poor insight into her motivations for becoming aggressive with her mother.

Patient Health Questionnaire – 9

1. In the past 2 weeks have you felt little interest or pleasure in doing things you used to enjoy?

1. Yes, Several days – +1

1. In the past 2 weeks, have you been feeling down, depressed, or hopeless?

1. Yes several days – +1

1. In the past 2 weeks, have you had trouble falling or staying asleep, or sleeping too much?

1. No not at all– +0

1. In the past 2 weeks, have you been feeling tired or having little energy?

1. Nearly every day – +3 (little energy)

1. In the past 2 weeks, have you had poor appetite or been overeating?

1. Yes, Several days (poor appetite) – +1

1. In the past 2 weeks, have you been feeling bad about yourself or that you are a failure or have let yourself or your family down?

1. Yes, several days – +1

1. In the past 2 weeks, have you had trouble concentrating on things, such as reading the newspaper or watching television?

1. Yes, several days – +1

1. In the past 2 weeks, have you been moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?

1. Yes (moving slowly) several days – +1

1. In the past 2 weeks, have you thought that you would be better off dead, or thoughts of hurting yourself in some way?

1. Not at all – – 0

Total Score – 9 – Suggests mild depression which may require only watchful waiting and repeat at follow-up.

DIFFERENTIAL DIAGNOSIS

1. Schizoaffective disorder: Based on the patient’s history frequent visits to CPEP for delusions of persecution especially with her mother, her current depressed mood, flat affect, history of a manic episode, and decompensating after discontinuation of lithium a mood stabilizer, the patient is likely suffering from schizoaffective disorder bipolar type rather than schizophrenia and bipolar type 1 as separate diagnoses.
2. Schizophrenia: Based on the patient’s current presentation of flat affect, lack of emotional expression, and delusion of persecution, schizophrenia can be considered. However, the patient has a history of manic episodes and is currently mildly depressed and is symptomatic off of a mood stabilizer. The diagnosis of schizoaffective disorder is more likely.
3. Delusional Disorder: Given her long history of CPEP admission for delusions (>1 month) of her mother stealing from her, and harming her, delusional disorder can be considered. However, since her behavior is bizarre, and she has presented in the past with both depressed and elated mood, delusional disorder is less likely.
4. Drug-induced psychosis: The patient has a history of marijuana use 1-2 times per week. Marijuana is known to induce acute psychosis. This can be ruled out with a THC drug test in addition to urine toxicology. Given the long history of delusions, manic episodes, and current depressed mood with flat affect, this diagnosis is less plausible.

Diagnosis:

Schizoaffective disorder, bipolar type

ASSESSMENT

23-year-old African American female, unemployed on social security income, domiciled with mother (Priscilla, 929-555-7873 ), with past psychiatric history of Schizophrenia, Bipolar Disorder Type 1 and past medical history of DiGeorge Syndrome, brought in to CPEP my EMS, activated by mother, for reported agitation. The patient states she got into an argument with her mother after not being able to go outside. She is unable to recall the details of the argument but admits to breaking objects and hitting her mother. She has a history of manic episodes and delusions of persecution that her mother is trying to steal from her and harm her. She is currently following up with QHC AOPC under the care of a psychiatrist Dr. Samee. She is compliant on Vraylar 3mg daily, Cogentin 0.5 mg daily. The patient was on lithium 600 mg in addition to Vraylar and Cogentin, however, the lithium was discontinued on 08/14/2020 by Dr. Samee, as per note, patient and mother reported controlled anger and improved outbursts and requested to discontinue Lithium.

Collateral information was obtained from her mother Priscilla who reported the patient was agitated when the patient was told her SSI check did not come in yet. Her mother tried to explain to her the checks come in on the 1st of every month but the patient was becoming aggressive and did not listen. The patient was claiming the mother was taking her SSI checks. The mother reports the patient punched her in the stomach and became very violent.

 

Patient was seen in CPEP triage. She was calm and cooperative but appeared emotionless. She is alert and oriented to person, place, time, and situation. She was appropriate in appearance and had good hygiene. Patient stated that her mood was “not good” and had a flat affect. Patient maintained good eye contact. Her speech was slow, rhythm was monotone, and volume was low. Patient’s insight to her conditions was appropriate but insight to her altercation with her mother was poor. Her judgment was within normal limits. Patient admits to marijuana use and denies suicidal/homicidal ideations, auditory/visual hallucinations, alcohol, and other illicit drug use. The patient’s labs were reviewed from last visit and was within normal limits. At this time the patient is not a danger to herself or others, but given her prior history, recent aggressive behavior towards her mother, depressed mood, and flat affect, the patient will benefit from CPEP admission for overnight observation. Will restart Lithium, discussed with the patient and patient’s mother who agreed with the plan.

 

PLAN

1. Restart: Lithium 300 MG capsule, Take 1 capsule (300 mg total) by mouth nightly
2. Admit to CPEP overnight for further psychiatric observation and to monitor response to Lithium.
3. CBC, CMP, Lithium levels, Beta-HCG and Urine toxicology to evaluate if drug-induced presentation
4. Review lab results
5. Obtain an EKG due to patient’s cardiac history, and assess for QTc prolongation
6. Continue

1. 1. Cariprazine (VRAYLAR) 6 MG Cap capsule, Take 1 capsule (6 mg total) by mouth daily.
   2. Benztropine (COGENTIN) 0.5 MG tablet, Take 1 tablet (0.5 mg total) by mouth nightly.
   3. ASPIRIN 325 MG EC tablet, take 1 tablet by mouth every day
   4. Metoprolol succinate er (TOPROL) 25 MG 24 hr tablet

1. Consult the Social Work team to discuss shelter and housing options with the patient and arrange outpatient follow-up with Dr. Samee.
2. Re-evaluation in the morning
3. Repeat vitals in the morning
4. Contact the patient’s mother when the patient is ready for discharge
   

   2. Article and Summary 

Link: Article

I chose this article since it is a meta-analysis and published within the past 5 years. This study had a large number of participants and the studies included were cohort studies. There were 10 studies included in this meta-analysis. The inclusion criteria were Cohort and cross-sectional studies that assessed cannabis use with dose and frequency and psychosis-related outcomes with validated clinical measures. All levels of exposure were studies not just comparing any cannabis use with no use. Diagnostic outcomes of the selected studies included a diagnosis or first admission for schizophrenia, a diagnosis of schizophreniform, a first contact with the clinical services for a first episode of psychosis or the presence of psychotic symptoms over a certain threshold set in each study. There was a consistent increase in the risk of psychosis-related outcomes with levels of cannabis exposure in all the included studies. There was a positive association between the extent of cannabis use and the risk for psychosis. The pooled analysis reported about a 4-fold increase in the risk for the heaviest users a 2-fold increase for the average cannabis users in comparison to non-users.

3. Site evaluation presentation summary 

I had two site evaluations. I presented the H&P above for my first site evaluation. I choose this case because the patient had a chromosomal abnormality which caused her to have DiGeorge Syndrome. It was an interesting case since people with DiGeorge Syndrome are at higher risk of having schizophrenia. This case generated an interesting conversation about DiGeorge Syndrome. I felt like my first evaluation went a little better than my second since my case was more interesting in my first evaluation. I also prepared better for my first evaluation since I had more time at the beginning of my rotation as opposed to the end when I was studying. For my second evaluation, I presented a case on Major Depressive Disorder with psychotic features. My evaluator agreed with my diagnosis. I also presented my article on cannabis use and risk of psychotic disorders. For the future, I intend to get my H&Ps and prepare better for my final evaluation by doing my H&Ps 1 week prior to my final evaluation.

4. Typhon 

Link:Typhon totals

5. Self-Reflection

Exposure to new techniques or treatment strategies 

In CPEP I learned how to evaluate if a patient needed admission, discharge, or extended observation unit. If they are a threat to themselves or others is a clear reason to keep a patient. However, the patient presentation may not be so clear. I saw clinicians consider the patient’s family support, the patient’s ability to be compliant on medications, the likelihood that the patient will return the next day if they are discharged. Treatment plans considered all of these factors and more. I also learned about LAIs which are long-acting injectable antipsychotics which is a great option for patients that are non-compliant. These injectables can be given every month depending on the medication and they are easy to track.

Skills or situations that are difficult for you (e.g. presentations, focused H&Ps, performing specific types of procedures or specialized interview/pt. education situations) and how you can get better at them

At first, it was difficult to write a psychiatric note for me. There was a method in writing the HPIs and the first sentence had more information than the usual age, gender, past medical history, and chief complaint. The first line in a psychiatric note includes all of that information and marital status, living situation, who activated the EMS, and past psychiatric history. After the story of the patient including medications and compliance, the next paragraph was collateral information. This was also new to me. Obtaining collateral information is usually very helpful in evaluating a psychiatric patient. Collateral can be a friend, family member, manager of shelter, etc. someone that knows the patient well and can provide information about the patient’s baseline and the events leading up to the hospital visit. The last paragraph usually included a summary of the presentation and the mental status exam. Writing this type of note was new to me and it was a skill I was able to build upon throughout the rotation. I know that practice makes perfect and therefore the only way to write a great psychiatric note is to keep on writing them.

What did you learn about yourself during this 4-week rotation?

My perspective on psychiatry has drastically changed as a result of this rotation. I learned that I actually enjoy psychiatry. Initially, I found psychiatry intimidating, the medications, the diagnostic criteria for each psychiatric illness was difficult for me to grasp. Furthermore, I was uncomfortable with the Mental Status exam. Going into this rotation I was aware that there would be a big learning curve for me. I was used to the physical exam I have been doing for the past few months. The Mental Status exam is based on observation and history. I had to get used to noting my observations in my head as I was interviewing the patient. By the end of the rotation, I was able to do this with much more ease. Additionally, I would consider psychiatry as a field I would like to work in. I value the focus on history taking and obtaining collateral information. I find that these skills can make me a better clinician overall in any field.

Managing new types of patients and the challenges that arise from that

It was difficult managing psychiatric patients. I had a patient who told me he had a chip in his head but did not want to go into details.  He was very paranoid but to get more information I had be careful with how I asked questions to ensure he could trust me. To find out why he is paranoid and when the delusion started I had to ask questions like “when do you think the chip was placed?” and “why are you afraid of talking about the chip?.” I learned how to ask about the delusion without validating it. Other types of patients that were difficult to manage were the ones that were agitated and aggressive. They were often medicated with 2 mg of Haloperidol and 5 mg of Lorazepam. However sometimes just talking to them and answering their questions and explaining to them the plan would be enough to calm them down. As clinicians, we have to remember to place ourselves in that patient’s shoes, because it does not take much to develop a psychiatric illness. One traumatic event, an increase in dopamine levels, a decrease in serotonin, are just some things that separate us from psychiatric illness. The importance of mental health needs to be stressed in all fields of medicine and managing these new patients just reinforced that for me.