Chief complaint: “I’ve been thinking of killing myself for the last 4 days”

History of present illness: 43 year old male domiciled alone with no pmhx and pphx of ADHD self-presented to CPEP today due to worsening SI for the past 2 weeks. Pt endorses to having intent and a vague plan consisting of jumping off the roof of his apartment building or overdosing on medication. Pt admitted to previous suicide attempt 1 year ago by swallowing a handful of xanax. Pt admitted to recent separation from his wife 2 years ago, and has shared custody of his 8 year old son. Pt currently lives alone in an apartment and states that his recent divorce and need to move to a new apartment was “too overwhelming.” 

Upon evaluation, the patient appeared disheveled in hospital pajamas, guarded, with poor eye contact but remained cooperative throughout the interview. Pt displayed soft speech with a grossly linear thought process. Pt endorses having an “ok” mood at the time of the interview however appears with constricted affect. Pt reports poor sleep and adequate appetite.  Pt demonstrates regressed behavior with no SI, plans and intent but still remains unpredictable. Pt still meets the criteria for MDD without psychotic features.Given this presentation, the patient warrants further inpatient psychiatric stabilization for safe position plan back to the community.Pt denies current HI, AH, VH, substance use/abuse, manic symptoms or any legal problems.

Past Medical History:

-No past medical history

Past Psychiatry History:

– ADHD(attention deficit hyperactivity disorder) x unknown years.

Past Surgical history:

– No known surgical history

Medications:

– Mydayis(unknown dosage) for ADHD

Allergies:

– NKA

Family history:

• –  Mother, alive
• –  Father, alive
• -Brother, Alive (Bipolar II)

Social History

• Living situation: Lives alone in a one bedroom apartment,moving to Condo to live closer to work.
• Highest level of education: College, bachelors in Film.
• Employment: Assistant video editor at ABC news
• Relationship status: Separated( 2 years) 
• Sleep: Decreased sleep ( 4 hours), admits feels fatigued today.
• Appetite: Good
• Alcohol: Denies use
• Tobacco: Denies use
• Illicit drug use: Denies use
• Past arrest/incarceration history: None

Review of Systems:
General: Admits to insomnia.Denies any recent weight loss or gain, loss of appetite, night sweats, fever, or chills

Head: Denies headache, and vertigo.

Eyes: Denies visual disturbances, double vision, blurriness, excess tearing or dryness, photophobia, or pruritus.

Ears: Denies hearing loss, tinnitus, discharge, earache.

Pulmonary system: Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or PND.
Cardiovascular system: Denies any palpitations, hypertension, chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope, or known heart murmur.
Gastrointestinal: Denies abdominal pain, and nausea

Genitourinary system: Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence.

Nervous system: Denies seizures, headache, loss of consciousness, ataxia, loss of strength, change in cognition/mental status/memory, or weakness.
Endocrine system: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric: Admits to feeling anxious and depressed. Denies suicidal ideations or plans of self-harm.

 Physical Exam:

Vitals:

• BP: 136/81 (left arm)
• HR: 98 (regular)
• RR: 17 (unlabored)
• T: 36.8 C (oral)
• O2: 98% (room air)
• Height: 150cm    Weight: 104  kg BMI: 36.01

General:Obese,  male,disheveled, appears his stated age of 43 

Skin:Warm & moist; non-icteric; no rashes, no lesions.

Cardiovascular:Normal rate and rhythm. S1 and S2 present with no murmurs

Respiratory: Clear to auscultation bilaterally. No wheezing, rhonchi or rales.

Mental Status Exam: General

• 1)  Appearance: Obese , poor hygiene and body odor.
• 2)  Behavior and Psychomotor Activity: Calm and cooperative during interview,no tics,tremor or twitches. 
• 3)  Attitude Towards Examiner:Superficially cooperative and indifferent
• Sensorium and Cognition

• 1)  Alertness and Consciousness:Patient was conscious and alert throughout the interview.
• 2)  Orientation: Patient was oriented to the date, place, and time of the interview.
• 3)  Concentration and Attention: Displayed satisfactory attention, without genuine interest.
• 4) : Patient can read and write.
• 5)  Abstract thinking:Ability to abstract was concrete
• 6)  Memory:Patients remote and recent memory were unimpaired
• 7)  Fund of information and knowledge: Patient’s intellectual performance was unremarkable.

Mood and Affect

1) Mood: Patient’s mood is disgruntled about current state

2) Affect: Patient’s affect is constricted
3) Appropriateness: Mood and Affect were congruent throughout the interview

Motor

1) Speech: Patient’s speech was normal, spontaneous speech production.

 2) Eye contact:Poor eye contact throughout the interview

3) Body movements: Normal body movements.

Reasoning and Control

• 1)  Impulse control: Patient has fair impulse control.
• 2)  Judgment: Patient has fair judgment, stating he understands his thoughts were dangerous to himself and needed help to overcome them.
• 3)  Insight: Good insight into his condition, understands that he needs help as these feelings are not normal. 

Assessment: G.G is a 43 y/o male with a PPHx of ADHD BIB self for worsening SI in CPEP, admitted to inpatient psych. Worsening SI is attributed to psychosocial stressors including separation from his wife and needing to move to a new apartment on his own. Today the patient is in good behavioral control, has poor hygiene and body odor, suggesting poor ADLs. Pt continues to isolate and remains depressed similar to previous days.Pt symptoms significantly impairs his ability to function, still meeting the criteria for MDD.Given this presentation, the patient warrants further inpatient psychiatric stabilization for safe position plan back to the community.

Differential Diagnosis:

• – Major Depressive Disorder: Major depressive disorder is characterized by at least 5 of the (SIGECAPS) symptoms for more than 2 weeks, with one of the symptoms either being depressed mood or anhedonia. Patient had presented with symptoms of SI, insomnia, fatigue, anhedonia along with the depressed mood the past 2 weeks which exacerbated in the last 4 days. These symptoms caused significant impairment to his social/work life which caused him to be admitted for further psychiatric observation.
• –  Adjustment Disorder: Adjustment disorder is a mental health condition characterized by a significant emotional or behavioral reaction to a stressful life event or change(identifiable stressor. This disorder begins within 3 months of the stressor, which is seen in my patient who stated one of the triggers to his SI was being overwhelmed to start packing. My patient recently decided to move to a condo which is closer to work and has taken significant stress from leaving his old house.
• –   Bipolar II: Bipolar II is characterized by 1 MDE and a hypomanic episode. Patients presented with MDE symptoms and symptoms such as irritable mood and impulsivity. Patient also has a Fhx(brother) with Bipolar disorder which is the greatest risk factor, increasing his likelihood 10x.
• –   Persistent Depressive Disorder: Dysthymic disorder is characterized by a depressed mood the majority of the day on most days lasting >2 months. My patient did state that he has taken the divorce from his wife(2 years ago) very hard and has generally felt depressed that they could not make things work. But another key feature in diagnosing PDD is never being without symptoms> 2 months at a time, which my patient denies. He states he recently started to have depressive symptoms that interfered with his daily life.

Plan:

• Patients continue to require inpatient admission for further stabilization. 
• Continue current medication regimen

Bupropion 300 mg PO daily for depression, including concentration/focus symptoms, can titrate up as clinically indicated.

Vilazodone 30m PO daily for depression

Hold Myadias given unclear ADHD diagnosis and to minimize polypharmacy.

• VS per unit Protocol(24 hours)
• Observation(Q30)
• Continue to encourage participation in group activities 
• Start Benadryl 50 mg PO PRN nightly for insomnia. 
• Ativan 2 mg PO Q8H for anxiety.
• Referral to outpatient psychologist pending discharge. 

Dispo: Pending Psychiatric stabilization and mediation optimization, consider family meeting closer to discharge.