Full Name: M.T.
Date of Birth: 02/05/1956
Admitted date: 10/27/2022
Location: Elmhurst Hospital
Source of Information: Self
Reliability of patient: Unreliable
Mode of Transport: EMS
Chief Complaint: “Fine” x 1 day
History of Present Illness:
M.T. is a 66 y/o F, divorced, unemployed with a past medical history of DM, HTN, HLD, and a self-reported PPH of Bipolar I Disorder, with most recent episode depressed. On 08/2022, patient was BIBEMS after a suicide attempt by taking a large amount of Ambien and insulin. She was initially treated in ICU for an unknown overdose with suspicion of sepsis, then downgraded to regular medical floor upon improvement of mental status. Patient then attempted to strangle herself with monitoring cables and was subsequently transferred to the inpatient psychiatry unit for further management. However, after 3 days in psychiatry unit, patient presented with another episode of diabetic ketoacidosis, requiring return to intensive care medical unit. During this medical treatment course, patient stopped accepting all oral intake, food, and fluids, and stopped taking medications requiring court-mandated treatment for severe and fluctuating episodes of hypo and hyperglycemia as a result, along with severe electrolyte abnormalities.
Upon stabilization of multiple medical comorbidities, the patient was eventually transferred back to inpatient psychiatry for further treatment of severe depressive episode with multiple suicide attempts. Since arrival at the psychiatric service, patient again refused to accept all offered medications, and therefore, court-mandated treatment was renewed for psychiatric treatment.
M.T. has been in Elmhurst Psychiatry Inpatient service for 201 days. For the past 6 months, Notes per EMR state the patient repeatedly refuses to get out of bed, shower and is selectively mute when speaking to staff. Patient occasionally gets up to use the bathroom in her room and eats lunch in the community area only a handful of times with a lot of encouragement. Patient has a history of UTI induced by indwelling urethral catheter and currently has a catheter in place.
Patient refuses discharge to a nursing home but does not have adequate care due to her 2 sons refusing to take care of her, stating they do not have time/resources. Patient has a brother that states he cannot take care of M.T. because his wife is sick with cancer and he is traveling back and forth from Florida. On 5/12, M.T. agreed to be discharged to a subacute rehab facility. That day, the patient asked questions about the facility saying “Where is the facility located ?” as well as other full sentences.
Today (5/16) the patient is refusing to use full sentences and is seen in bed facing the wall. After encouragement, the patient nods her head when asked if she feels sad because she is not being discharged home. Patient denies suicidal ideations, auditory or visual hallucinations
Past Medical History:
HTN
HLD
Type 1 Diabetes
Bipolar 1 Disorder
Urinary Tract Infection associated with indwelling urethral catheter
Per Hospital EMR
Past Surgical History:
Denies previous surgeries or blood transfusion
Allergies:
No known drug allergies
Medications:
Aripiprazole Aristada 882 mg IM monthly for mood stabilization
Bupropion XL tablet, 150 mg, PO, Daily for depressed mood with low energy
Mirtazapine 45 mg PO at night for depressed mood with low appetite
Insulin lispro injection 0-10 units, SC, TID with meals for diabetes
Selenium Sulfide 2.5% lotion, Daily for dandruff
Labetalol – 100mg tablet, PO, every 12 hours for HTN
Lisinopril – 40mg tablet, PO, once daily for HTN
Family History:
Mother- deceased, unknown age and unknown cause of death
Father – decreased, unknown age and unknown cause cause of death
Grandparents -Pt denies knowledge of grandparents
Brother – older brother
Son – 35 y/o living and well
Son – 37 y/o living and well
Social History:
Travel – Pt denies any recent travel
Marital history – Pt is divorced, currently single
Occupational history – Denies to answer about occupational history
Diet- currently hospital food (eggs, toast, rice, vegetables, chicken) – diabetic high protein, 1800-2000 kcal/day
Exercise – Pt denies exercise
Sexual Hx- Denied to answer questions about sexual history
Education: Denied to answer question about education
Substance Use: Denies substance use
Review of Systems: (Per Hospital EMR)
General – Pt is not verbalizing her condition
Cardiovascular – Patient has hx of HTN and HLD
Gastrointestinal system – pt has suspected liver cirrhosis
Genitourinary system – Notes history of UTI’s and pt currently has an indwelling catheter.
Psychiatric – Pt admits to history of suicide attempts, bipolar disorder and feeling depressed. Pt denies elaboration and says we can “look at the chart”.
Physical
Vitals: As of 5/16 per Hospital EMR
| BP: 102/67 | |
| Pulse : 67 | |
| Temp: 98.2 | |
| Resp: 28 | |
| Ht: 5’3 | |
| Wt: 101 | |
| SpO2: 99% | |
| BMI: 17.9 |
MENTAL STATUS EXAM
1. Appearance: M.T. appears to be disheveled (dandruff, nails uncut), curled up in bed
2. Behavior and Psychomotor Activity: M.T. displays disorganized behavior and psychomotor retardation.
3. Attitude Towards Examiner: M.T. appears guarded and uncooperative.
Sensorium and Cognition
1. Alertness and Consciousness: M.T. maintains consciousness during a conversation. M.T. is aroused spontaneously
2. Orientation: M.T. was oriented to the time of day, place of the exam and the date
3. Concentration and Attention: M.T. demonstrated good attention. M.T. refuses to perform tedious psychological testing
4. Capacity to Read and Write: M.T. has good reading and writing ability
5. Abstract Thinking: M.T. is able to use metaphors to explain how she feels. M.T. can perform simple mathematical calculations.
6. Memory: M.T.’s remote and recent memory are normal
7. Fund of Information and Knowledge: M.T.’s intellectual performance is sufficient
Mood and Affect
1. Mood: M.T. mood was sad that she is not going home
2. Affect: M.T. affect appears depressed with frowning.
3. Appropriateness: M.T.’s was appropriate during interview.
Motor
1. Speech: M.T.’s speech is soft and incoherent
2. Eye Contact: M.T. displays poor eye contact
3. Body Movements: M.T. displays psychomotor retardation while walking and eating
Reasoning and Control
1. Impulse Control: M.T.’s impulse control is satisfactory
2. Judgment: M.T. displays poor judgment
3. Insight: M.T. displays poor insight
Pt declined physical examination.
Differential diagnosis:
Bipolar I Disorder, most recent episode depressed – Patient currently presents with markedly depressive symptoms (dysphoric affect, low appetite, poor energy, psychomotor retardation, soft speech, hopelessness, anhedonia, and multiple recent suicide attempts). Per history, patient has multiple prior hospitalizations for manic episodes and was treated with Lithium.
Major Depressive Disorder – M.T. displays a depressed mood nearly everyday, has loss of interest or pleasure in almost all activity nearly everyday. M.T. weight has reduced since admission M.T. also displays psychomotor retardation while eating or walking to the bathroom. She is on a 1:1 watch 24 hours of the day for fall risk. M.T. notes fatigue most of the day. M.T. notes she often has trouble sleeping. However, patient has had multiple episodes of suicide attempts including while in the hospital.
Persistent Depressive Disorder (Dysthymia) – Patient has been in the Psychiatric Inpatient Unit for 6 months. While dysthymic disorder cannot be confirmed until 2 years, the patient shows little to satisfactory improvement when asked about mood, and when visualized on exam despite treatment.
Assessment and Plan:
M.T. is a 65 y/o Female who is divorced, of cuban heritage, has two adult sons, retired, domiciled alone with a PMH of DM, HTN, HLD and a PPH of Bipolar Disorder, Depressive type. Patient is uncooperative with psychiatric evaluation and refuses to answer questions verbally.
Plan:
Patient should be on 1:1 watch for fall risk and suicidality. Patient must maintain a diabetic diet. M.T. should have vitals taken per unit routine by nurses and may ambulate when tolerated. Patient is to continue her scheduled medications. Instruct nurses to bathe patient, wash hair, and change foley catheter or call urology if needed. Patients will have arrangements to be discharged to a sub-clinical acute rehabilitation per social worker.
Discourse:
Patient is scheduled for possible discharge on Monday (5/22) to a subacute rehab facility.
