Chief complaint: “My mom brought me here”

History of present illness: 22 y.o  AA female, domiciled with mother, unemployed with no past medical or psychiatric history BIBEMS activated by mother for aggressive and erratic behavior at home.  Initially when asking about recent events she stated “I can’t explain” and mainly responded with closed-ended responses. Pt states she was at home with her mother feeling irritable and was unable to elaborate why she felt that way. States her mother activated EMS because “I yelled at her.” Pt endorses seeing “orbs” and hearing spirits since 2019 but did not elaborate further regarding content or significance of her perceptual disturbances and appeared internally preoccupied, mumbling at times. Pt grossly denied manic history, though reports feeling irritable with “heightened energy” in the past. Currently denies history of SA or SI, though states she engaged in SIB via cutting. Denies history of major depressive disorder or current symptoms of depression. Pt endorses good appetite and states she sleeps 8-9 hours per night.  

Collateral information was provided by mother, who was present with her. Mother reports that she heard a bang on the wall, went to check on the patient who was in the living room saying “they won’t  leave me alone” and started cursing her out. Mom reported that the patient asked “you can’t hear them?”  Followed by the patient pushing the mother. States pt throws objects at the wall, taped up the bathroom with sticky pads, and is destructive of home property. Mother reports that a little less than a year ago, pt reported thoughts of jumping off the terrace to which police were called. Pt was not hospitalized because police stated “she was underage.” Reports history of patient staying up all night constantly laughing, screaming and exhibiting disorganized and aggressive behaviors. Refuses to leave her room and remains isolated with no friends. Mother’s personal history of schizophrenia.

Upon evaluation today, patient reports feeling “good” overall, expressing she is looking forward to being discharged soon to her father. She reports requiring PRN medications for anxiety and restlessness, with good affect. Despite ongoing auditory hallucinations, patient states that they are not distressing to her and reports feeling safe. She denies any current suicidal idealation, homicidal ideation or visual hallucinations.

Past Medical History:

-No past medical history

Past Psychiatry History:

-No past psychiatric history.

Past Surgical history:

– No known surgical history

Medications:

– No current medications 

Allergies:

– NKA

Family history:

• –  Mother, alive(schizophrenia) 
• –  Father, alive(no contact 2-3 years until recently)
• -Brother, Alive- Incarcerated
• – Half brother, Committed suicide April 2023

-Half brother, Alive, -possible mental illness(unspecified) would physically abuse J.G

-Sister, Alive , military enlisted

Social History

• Living situation: Currently lives with mother and siblings in an apartment building. J.G was in foster care for 6 months earlier in her childhood.
• Highest level of education: Highschool.
• Employment: Unemployed
• Relationship status: Single
• Sleep: 8 hours (took Ativan 2mg for restlessness)
• Appetite: Good
• Alcohol: Denies use
• Tobacco: Denies use
• Illicit drug use: Denies use
• Past arrest/incarceration history: None

Review of Systems:
General: Admits to restlessness when trying to sleep.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 . Denies suicidal ideations or plans of self-harm.

 Physical Exam:

Vitals:

• BP: 91/57 (left arm)
• HR: 98 (regular)
• RR: 18 (unlabored)
• T: 36.7 C (oral)
• O2: 97% (room air)
• Height: 1.651 m    Weight: 55.2  kg BMI: 20.25

Mental Status Exam: General

• 1)  Appearance: Slim young African American female, well groomed, resting comfortably. 
• 2)  Behavior and Psychomotor Activity: Calm and cooperative during interview,no tics,tremor or twitches. 
• 3)  Attitude Towards Examiner: Cooperative and engaged throughout the interview.
• 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 appropriate concentration with interest in the treatment plan.
• 4) Capacity to read and write: Patient can read and write.
• 5)  Abstract thinking:Proper ability to abstract, average ability to use deductive reasoning.
• 6)  Memory:Patients remote and recent memory were unimpaired
• 7)  Fund of information and knowledge: Patient’s intellectual performance consistent with level of education.

Mood and Affect

1) Mood: Euthymic 

2) Affect: Euphoric
3) Appropriateness: Mood and Affect were congruent throughout the interview

Motor

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

 2) Eye contact: Fair 

3) Body movements: Normal body movements.

Reasoning and Control

1)Thought content: Bizzare thoughts, aliens.

• 2)  Impulse control: Patient has fair impulse control.
• 3)  Judgment: Patient has fair judgment, still able to hear the voice of boyfriend telling her she will be discharged soon. 
• 4)  Insight: Good insight into her condition, belief with medications, voices will come to an end.  

Assessment: 22 y/o female, diagnosed with schizophrenia(HCC) admitted to inpatient psychiatry.  On assessment, patient is calm, cooperative, well-dressed in personal clothing, keeping to herself in her room, preoccupied with discharge, endorsing intermittent auditory hallucinations of boyfriend(Brian), however with significant improvement in symptomatology since admission. Appropriately anxious regarding disposition to her father she has not lived with in over a decade. Patients will benefit from continued in-patient psychiatric hospitalization for further observation, evaluation, medication management and psychotherapy at this time.

Differential Diagnosis:

• – Schizophrenia: Schizophrenia is characterized by continuous signs of disturbance  >6 months w >1 month of 2+ more symptoms of delusions,hallucinations, disorganized speech, behavior or negative symptoms. My patient presents with auditory hallucinations, disorganized speech and behavior that has been going on for greater than 6 months. The patient’s mother also having schizophrenia also supports this diagnosis.
• Schizoaffective: This is characterized by a MDE or maniac episode concurrent with the symptoms of schizophrenia.With the schizophrenia symptoms of delusions and hallucinations >2 weeks without the mood disorders symptoms. My patient presented irritably on presentation with some symptoms of hypomania but did not meet the requirement for a mood disorder. 
• Bipolar 2 disorder: A hypomanic episode is characterized with abnormally elevated, expansive or irritable mood plus an increase in energy/activity> 4 days.My patient came in stating she felt irritable with heightened energy in the past, prompting us to ask her more questions regarding this episode. Since my patient denied symptoms of depression and other mania symptoms this differential is less likely.   
• Schizotypal personality disorder: Schizotypal personality is characterized by a pervasive pattern of eccentric behavior and peculiar thought patterns. My patient admitted to seeing orbs and hearing spirits which fits the symptoms of magical thinking in patients with schizotypal. But with the presentation of the symptoms such as disorganized behavior and aggression, this is less likely a diagnosis. 
• Plan:

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

Scheduled Medications

• Ferrous Sulfate,325 mg, Oral, Daily
• Risperidone 2mg, Oral, Daily
• Risperidone 3mg, Oral, Nightly
• Trazodone, 50 mg, Oral, Nightly

PRN

• Ativan 2 mg for Anxiety

• VS per unit Protocol(24 hours)
• LAI Sustenna IM 234 mg today(02/23), 156 mg IM injection on Tuesday(02/27)
• Start Trazodone 50 mg PO PRN nightly for insomnia. (Educated regarding habit forming potential of benzo use for trouble sleeping and instead offered trazodone).
• Referral to BOOST(Better outcome with ongoing specialized treatment) program pending discharge. 

Dispo: Plan to discharge to father on Tuesday(02/27), with follow up appointment Boost clinics 03/05.