Substance Abuse History: 5 to 6 drinks every 2 weeks. No recent use of alcohol, tobacco, or drugs.

Transcription

1 Date of Admission: [DATE] Date of Discharge: [DATE] History of Present Illness: This is a 39-year-old Caucasian married male with no previous psych history who is brought in by his wife on the urging of attorney family friend secondary to the patient's odd statements and behaviors with paranoia and insomnia for the past 10 days. He has a history of peaks and depressive moods cycling approximately two weeks since young adulthood, but never meeting diagnostic criteria or disabling him. However, 10 days ago, the patient had a very significant distressing and possibly financial devastating work stressor. It evolved money but neither the patient nor the wife would like to provide details at this time. The first thing the patient's wife noticed was decreased sleep with much tossing and turning 7 days prior to admission. The patient and his wife drove to [PLACE] and the wife noted decreased speech and exasperated sighs and the patient will become more frustrated until he would not sleep more than 3 hours per night. One week ago, the patient flew back to [PLACE] by himself and the wife joined him on the following day and noted him to be very paranoid and having concerns regarding the mafia. He did not want this mentioned, however. He also had concerns about computer viruses and shifting of moneys through bank accounts. His wife had given him over-the-counter sleeping pills, but did not notice a change in sleep and he became more paranoid. He also had auditory hallucinations downstairs and thought that it was a mob and was checking bank accounts more frequently and having delusions about spreading computer viruses. At one point, he hoped something horrible was going to happen to happen to his wife. The patient does not want to give details and wishes to protect his wife. He is irritable, grandiose, and assumes responsibility for outside changes. He also has racing thoughts, increased goal-directed behavior, ideas of reference. He denies SI or HI at this time. Past Psychiatric History: The patient has had episodes of depressed mood 8 years ago, status post mother's death, but no prior treatments with medications, therapy, or hospitalizations. Medical Problems: None. Allergies: No known drug allergies. Home Medications: None. Substance Abuse History: 5 to 6 drinks every 2 weeks. No recent use of alcohol, tobacco, or drugs. Family History: Mother and two aunts with depression. Two aunts committed suicide. Social History: The patient met milestones on time. He was a good student. He graduated with a bachelor of Science. He has a 3-year-old and a 5-year-old, who are currently visiting grandparents in [PLACE]. He has some sort of job in sales in the technical industry. His current support system is his wife and family. He has no prior legal problems. No history of abuse or domestic violence. Mental Status Exam: On admission: He appears stated age, tall height, thin build, good hygiene, appropriate clothing. He is hypervigilant and extremely guarded with poor eye contact. He has no pressured speech, but very deliberant in his speech, so he is worried what he will say in peaks of delusion. He denies visual hallucinations or auditory hallucinations at this time. His thought process is linear and perseverative. His mood is guarded. Affect is restricted. Sensorium is alert and oriented x4. Average of estimated intelligence. Poor insight and poor judgment. Physical Examination: Please see physical exam on admission H and P dictated on [DATE].

2 Laboratory Data: From admission to discharge: Lipid screen shows cholesterol 153, triglycerides 42, HDL 61, LDL 81. CBC is within normal limits. Complete metabolic panel is within normal limits. RPR nonreactive. TSH and free T4 within normal limits. Urine drug screen was negative. UA was negative. Hospital Course and Treatment: The patient was admitted to the 3-south neuropsychiatric unit under the care of Dr. [NAME]. He was initially admitted to the 1-north unit and was started on Zyprexa. There was initial concern of bipolar with psychotic features, currently in a mixed state given the symptoms as described in the HPI. The patient was extremely guarded and refused to discuss details of the events leading up to admission. He was also noted to have significant psychomotor retardation and flat affect. Over the weekend that he had been admitted, Effexor was added 1 day after admission given the concern for more of a unipolar depression with psychotic features rather than bipolar. The following day, the patient was transferred from 1- north to 3-south neuropsychiatric unit due to the high psychotic acuity on 1-north and the patient feeling uncomfortable in that sort of milieu. Once on 3-south, the decision was made to discontinue the Effexor given the concern for possible bipolar disorder. He had continued on the Zyprexa and had been increased up to 15 mg at night, however, he did display excess daytime sedation and significant psychomotor retardation, therefore, the decision was made to cross titrate him from Zyprexa to Abilify. Therefore, he was started at 5 mg b.i.d. He tolerated this medication well without any additional side effects and was increased to 10 mg b.i.d. He continued to be very guarded and suspicious on the unit, and he would not interact with any peers or speak voluntarily to staff members. He was extremely flat with psychomotor retardation and would even walk slowly and talk in s low monotone voice. After a few days of the Abilify, he slowly began to open up more about the events prior to admission and did feel that, "perhaps I was blowing everything out of proportion" and admitted that perhaps his delusions and suspicions prior to admission were not reality based. He did admit to having concerns about the mob and hearing things as well as having concerns about dead bodies being dragged into his house. While on the unit, the first few nights, he did endorse vague visual hallucinations of an outline of a wheelchair in his room as well as auditory hallucinations of tires screeching and people talking that made him very suspicious for mafia activity. However, he slowly began to become less guarded and suspicious and slept well with Abilify and occasional use of Ambien as needed. His affect did become brighter and he became less suspicious and talked more voluntarily with the staff. Throughout admission, he denies any thoughts of self-harm or harm to others and very much wishes to go home given how much he missed his family as well as the fact that he felt that he was sleeping better and thoughts were more organized and he was less anxious. On [DATE], a family meeting was held with the patient, his wife, his brother, the social worker, and the resident physician. All questions and concerns were addressed during this meeting and the family was also educated that a provisional diagnosis of major depression with psychotic features was only a working diagnosis at this time and it would not be until long-term followup that one could be certain of his actual diagnosis, however, it is recommended that he continue on the Abilify the time being. He was having some excess daytime sedation, therefore, Abilify was changed to 20 mg all at night The prospect of initiating an antidepressant would be deferred to outpatient psychiatrist, however, this should be considered if his psychotic symptoms resolve, but he remains to be significantly depressed. At the time of the family meeting, the patient, his wife, and his brother did feel safe with him to return home that day given the fact that a followup appointment, who already been made for UCI Outpatient Psychiatry the following week. At the time of discharge, the patient denied any SI, HI, AVH, or PI. Mental Status Exam: On discharge: The patient appears stated age. Tall height, thin build, fair hygiene and grooming. He has improved eye contact, improved posture, mild psychomotor retardation. Speech is regular in rate and rhythm, low volume. Mood is "better." Affect is restricted, but mood congruent. Thought process is overall linear and goal directed. Thought content: Denies SI, HI, AVH, PI, or other delusions. He is alert and oriented x4. Average level of intelligence. Fair insight and fair judgment, improved since admission. Discharge Diagnosis(es) Axis I: Provisional diagnosis of major depression with psychotic features. Axis II: Deferred.

3 Axis III: Insomnia. Axis IV: Moderate, problems with occupational stress and poor coping. Axis V: 55. Discharge Medications 1. Abilify 20 mg at bedtime. 2. Ambien 10 mg as needed for insomnia. Discharge Instructions: The patient was discharged on a regular diet as tolerated and encouraged to remain active with daily physical activity and instructed to take medications as prescribed. He was also instructed to follow up with Dr. [NAME] on [DATE], at 8 a.m. as well as therapist, [NAME] on [DATE], at 3:30 p.m. The patient was instructed to call 911 or return to the nearest ER should he experience exacerbation of suicidal thoughts, homicidal thoughts, ( ) psychotic symptoms. Lastly, the patient was discharged in stable condition with his wife and brother. Electronically Reviewed and Approved By:, M.D.

4 Date of Admission: [DATE] Service Provided: Psychiatric Admission History and Physical Identifying Data: The patient is a 39-year-old Caucasian married male, high-functioning technical executive sales, lives at home with wife in [PLACE], admitted for paranoia and insomnia x10 days. Admitted on grave disability secondary to wife not comfortable taking him home. He came in voluntarily. History of Present Illness: Mr. [NAME] is a 39-year-old Caucasian male with no previous psychiatric history who was brought in by wife on urging of attorney family friend secondary to the patient's odd statements and behavior. He has a history of peaks and depressive moods cycling approximately two weeks since young adulthood, but never meeting diagnostic criteria or disabling him. However, ten days ago, the patient had very significant distressing and possibly financial devastating work stress, it involves money but neither the patient nor the wife want to provide details. The first thing the patient's wife noticed was decreased sleep with lots of tossing and turning seven days prior to admission. The patient and his wife drove to [PLACE], and the wife noted decreased speech and exasperated sighs, sleep, became more frustrated until he would sleep about three hours per night with increased awakenings and tossings and turnings. [DATE], the patient flew back to [PLACE] by self, and the wife had joined on [DATE] and found the patient to be very paranoid, having concerns regarding mob. He did not want this mentioned. Computer viruses, shifting of moneys through bank accounts. Wife gave sleeping pills over-the-counter, but no change in sleep. The patient became more paranoid. Heard a commotion downstairs and concerned it was a mob, checking bank accounts more frequently and having delusions about spreading computer viruses at one point told the wife it is happening tonight. It is the pulse. The patient will not give details to wife to "protect." He is irritable, grandiose, assumes responsibility for outside changes, positive racing thoughts, increased goal-directed behavior, activity in addition to insomnia, increased ideas of reference, no hallucinations, no HI, and no SI. Past Psychiatric History: Episodes of depressed mood eight years ago, status post mother's death, states I always see the down side, but no previous treatment with medications or psychotherapy. Past/Recent Medical Problems: None. Allergies: None. Medication History: None. Review of Systems: Review of systems was completely unremarkable. History of Alcohol and Substance Abuse: Five to six drinks. One episode q.2 weeks. No recent use. Family History of Mental Illness: Mother and two aunts with depression. Two aunts committed suicide. Social Developmental History: Met milestones on time, a good student. Graduated DS. Father, a 3-year-old and a 5-year-old both and grandparents were [LOCATION] in [PLACE]. He has a stressful job in the technical industry. Support Systems: Wife.

5 Mental Status Examination: Appears as stated age, tall, and thin. Hygiene is clean. Clothing is fine. He is hypervigilant and extremely guarded. Eye contact is poor. Appears to be very guarded, has no pressured speech, very deliberate in his speech as though he is worried about what he will say and delusions, see history of present illness. No visual hallucinations. Thought process is linear. Mood: Stays active and okay but very suspicious guarded. Sensorium: Alert and oriented x4. Word comparison is fine. Estimated intelligence average. He has some insight problem, but very poor judgment. Physical Examination Vital Signs: Vital signs were stable. Skin: Normal. HEENT: Normal. Lungs: Normal. Heart: Normal rate and rhythm. Abdomen: Flat, did not want a rectal. Extremities: No cyanosis, clubbing, or edema. Peripheral pulses are symmetric bilaterally. Neurological: Cranial nerves 1 through 12 are normal. Motor is normal and sensory is normal. Reflexes are 2+ throughout. Laboratory Data: Laboratories are pending. Admitting Diagnoses Axis I: Rule out bipolar disorder, type 1 versus type 2 versus psychotic disorder, not otherwise specified. Axis II: Deferred. Axis III: Insomnia. Axis IV: Work stress, very high expectations. Axis V: Global Assessment of Functioning is 19, currently high ( ) 80. Initial Treatment Plan 1. I admit to unit 1-North. 2. Check routine laboratories. 3. Begin Zyprexa, consider adding Depakote. 4. Contact the family.

6 Service Provided: Progress Note The patient continues to have some depressed mood, some poor concentration, and decrease in appetite. The patient's mood continues to be depressed. Restricted affect. Physical Review of Systems: Denies nausea, vomiting, or headache. Rest of physical review of systems within normal limits. No tremors seen on physical examination. The patient still with some poor sleeping. No tremors on physical examination. Denies auditory or visual hallucinations. The patient does report some paranoid delusions however. Assessment: Bipolar disorder with psychotic features. Continue the patient on his Zyprexa, and we will await for further response.

7 Service Provided: Progress Note Interval History: The patient is seen and examined today. The patient continues to be depressed with restricted affect. The patient states she cannot guarantee of safety if he were to leave the hospital. The patient is still with some suicidal ideation, with the patient's wife as well who is able to provide further information. The patient with significant guilt, decreased energy, and decreased concentration. The patient with a significant family history of depression as well. The patient with a low appetite, significant weight loss, and significant psychotic guilt still. The patient with significant psychomotor retardation. Physical Review of Systems: Denies nausea or headache. Rest of the physical review of systems within normal limits. The patient with poor sleeping as well. The patient received full and informed consent regarding Effexor, and we will start the patient on this medication tomorrow. Assessment: Major depressive disorder with psychotic features. Continue the patient on Zyprexa. We will start the Effexor XR tomorrow morning and we will await for further response. Continue with the individual psychotherapy.

8 Service Provided: Inpatient Progress Note Interim History: The patient was seen today, chart reviewed, and care plan discussed with treatment team. The patient remains psychotic, but compliant with medications. Reports no side effects. No nausea, vomiting, diarrhea, or headache. He has improved ADLs, good grooming, and interacting with staff and peers appropriately. Assessment: Bipolar ( ) mixed with psychotic features. Plan: Continue inpatient hospitalization. Continue individual, group, and milieu therapy. Continue current medications. The patient is awaiting stabilization.

9 Interim History: The patient was seen today, chart reviewed, and care plan discussed with treatment team. The patient remains psychotic. He is paranoid, believes that the mob may come and kill his family. He has got psychomotor retardation, blunted affect, continues to be somewhat suspicious and guarded, unable to contract for safety outside of the hospital. Continues to feel that he may harm himself. Family meeting with the patient's wife and brother; neither the wife nor brother feels comfortable with the patient home either. The patient is, however, compliant with medications. Reports no side effects. No nausea, vomiting, diarrhea, or headache. Assessment: Bipolar disorder, mixed, with psychotic features. Plan: Continue inpatient hospitalization. Continue individual, group, and milieu therapy. Increase Zyprexa to 15 mg p.o. nightly. Transfer the patient to Med/Psych floor.

10 Service Provided: Inpatient Progress Note Interval History: The patient was seen today, chart reviewed, and care plan discussed with treatment team. The patient remains psychotic with paranoid delusions and psychomotor retardations. Continues to have beliefs that the mob might be after him. He is reluctant to talk about certain facts. He is afraid that they will get in his chart. The patient has good ADLs and good grooming, currently contracting for safety in the hospital but unable to contract for safety outside of the hospital. Continues to state that he might harm himself when he has thoughts of wanting to harm himself. Assessment: Psychosis, not otherwise specified; rule out bipolar disorder mixed with psychotic features versus major depressive disorder with psychotic features. Plan: Continue inpatient hospitalization. Continue individual, group, and milieu therapy. Continue current medications. Start Abilify 5 mg b.i.d. Increase Zyprexa 10 mg nightly.

11 Service Provided: Inpatient Progress Note Interval History: The patient was seen today, chart reviewed, and care plan discussed with the treatment team. The patient remains psychotic, paranoid, agitated, unable to contract for safety outside the hospital and remains gravely disabled as a result of his mental illness. He continues to have guarded behavior, appears responding to internal stimuli, blunted affect, psychomotor retardation, and thought blocking. The patient has moderate ADLs good grooming and vague suicidal ideation. Unable to contract for safety outside the hospital. Assessment: Psychosis not otherwise specified, rule out bipolar disorder mixed with psychotic features versus major depressive disorder with psychotic features. Plan 1. Continue inpatient hospitalization. 2. Continue individual, group, and milieu therapy. 3. Continue current medications except increase Abilify to 10 mg b.i.d. Offered the patient Klonopin 0.5, the patient refused. 4. Continue inpatient hospitalization. 5. The patient is awaiting stabilization.

12 Service Provided: Inpatient Progress Note Interval History: The patient was seen today, chart reviewed, and care plan discussed with treatment team. The patient remains mildly psychotic and depressed, but doing much better in a controlled environment. He is compliant with medications. He reports no side effects. No nausea, vomiting, diarrhea, or headache. He has good ADLs and good grooming. He has a viable plan for self-care outside the hospital and ready to be discharged. Family meeting this afternoon with the patient's wife, social worker, and primary treatment team indicated the patient felt comfortable and family felt comfortable taking the patient home. The patient was advised of what to do if the patient started feeling unsafe at home, I want ( ) return to the emergency room. Assessment: Major depressive disorder with psychotic features, ruled out bipolar disorder, depression with psychotic features. Axis II: Deferred. Plan: Discharge the patient to home. Continue current medications, Abilify 20 mg nightly and follow up with outpatient psychiatrist the patient is choosing. The patient is scheduled to follow up with Dr. [NAME] on [DATE].