Chief complaint: “I made a mistake ”

History of present illness: 

22y.o male, domiciled with partner, unemployed, undergraduate student at Hunter College, no known PMH, PPHx of MDD, No IPP admissions or CPEP visits, no hx of SA or SIB,  BIBEMS activated by brother after attempted suicide after intoxication(18 beers) via overdose on naproxen, cyclobenzaprine and diphenhydramine. On  assessment, the patient is wearing a hospital gown, appears kempt, fair self hygiene and with facial piercings. Pt today reports that he “made stupid decisions” after a night of drinking following a fight with his brother. Patient states it was a recipe for disaster. Pt reports that he saw his therapist on 4 days ago before SA and is adamant that the therapist will vouch for him that he is not a suicidal person. Patient reports that he was shocked by CPEP evaluation, wanted more people to talk to him about medications and was shocked by people in CPEP. Patient states he just wants to go home to his partner and dog. He states he is already in talk therapy and ‘messed up’ by forgetting to get a refill of lexapro for a few days. Patient states this has happened in the past and thinks his episode was precipitated by him not taking his medications with the ‘storm’ that occurred that evening. Patient states he has not been suicidal before and denies SI or plan in past and present. He admits to regretting his attempt and says he tried to vomit up the meds he had taken. When that didn’t work he immediately called his brother who came over and said 911 should be called. At present, given patients PPHx of MDD with recent SA, he presents an acute risk to self and requires IPP involuntary admission for medical stabilization. Patient denied sleep problems, manic symptoms

Past Medical History:

-No past medical history

Past Psychiatry History:

– MDD x 1 years

Past Surgical history:

– No known surgical history

Medications:

– Lexapro (escitalopram) 15 mg for major depressive disorder   

Allergies:

• PCN allergy (reports rash when first taken years ago)

Family history:

• –  Mother, alive(no known past medical history)
• –  Father, alive(HTN)
• –  Brother, alive(no past medical history)

Social History

• Living situation: Lives with a current partner in an apartment building.
• Highest level of education:  Highschool, currently undergraduate pursuing a degree in Music.
• Employment: Recently lost job at bakery, currently unemployed 
• Relationship status: Girlfriend (1 years)
• Sleep: Slept 8 hours
• Appetite: Good
• Alcohol: 3-4 cans of beer per week. Drank 18 cans of beer on the day of his SA.
• Tobacco: Denies use
• Illicit drug use: Denies use
• Past arrest/incarceration history: None

Review of Systems:
General: 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:  Denies depression ,anxiety, suicidal ideations or plans of self-harm.

 Physical Exam:

Vitals:

• BP: 132/80 (left arm)
• HR: 88 (regular)
• RR: 18 (unlabored)
• T: 36.8 C (oral)
• O2: 98.2% (room air)
• Height: 1.829 (6’)   Weight: 122  kg BMI: 36.61

General:Obese,  male, well groomed appears his stated age of  22.

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: Well groomed and overweight, dressed in hospital gown 
• 2)  Behavior and Psychomotor Activity: Calm and cooperative during interview, no tics, tremor or twitches. 
• 3)  Attitude Towards Examiner: Cooperative, answering questions appropriately when prompted.
• 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, with genuine interest in regards to treatment plan.
• 4) Capacity to read and write: Patient can read and write.
• 5)  Abstract thinking: Ability to abstract was concrete, 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 was unremarkable.

Mood and Affect

1) Mood: Patient’s mood is Euthymic.

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

Motor

1) Speech: Patient’s speech was normal in rhythm, volume and rate. 

 2) Eye contact:Engaging in proper eye contact.

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: Pt has some insight, in regards to his suicide attempt, pt states it was a bad mistake. In regards to his alcohol use disorder, pt denies it being an issue. 

Assessment: L.R is a 22 year old male with PPHx of MDD, alcohol use disorder, admitted after suicide attempt via OD on multiple meds after conflict with family. Currently somewhat insightful regarding substance use and poor coping skills. Discharge focused but amenable to plan for Chem Dep referral. 

Differential Diagnosis:

• – Major Depressive Disorder: Given my patient has a past psychiatric history of major depressive disorder and presence of suicidal behaviour, MDD is the primary consideration. Recurrent depressive episodes are common in MDD(increased risk) and suicidal idealtion or attempts are among the more serious symptoms. Based on symptoms at the presentation, the patient fits the criteria for a relapse episode of MDD.
• – Alcohol use Disorder: My patient reports a history of drinking 3-4 cans of beer weekly which does not necessarily meet the criteria for Alcohol use disorder. But his binge drinking of 18 beers on the day of his SA should raise some concerns for this disorder. Based on collateral information provided by the brother, we know that our patient had taken a recent breakup with ex-gf very hard which led him to increase the amount of alcohol intake.
• – Medication Non-adherence: Patient admitting to not refilling his prescription for lexapro and acknowledgment that this has happened in the past suggest a potential contributor to his current presentation. Non adherence to psychiatric medication can lead to destabilization and increase the risk of suicidal behavior.
• –Adjustment disorder: This is characterized by marked distress that is out of proportion to the severity or intensity of the stressor. My patient had told me that his recent breakup with his ex girlfriend has been causing significant impairment to his daily life. But he reported this was over a year ago and with adjustment disorder, symptoms usually occur within 3 months of stressor onset and resolve by 6 months making this less likely. However, our recent fight with his brother could be another stressful life event that led to distress.

Plan:

• Patients continue to require inpatient admission for further stabilization. 
• Continue current medication regimen
  • Scheduled medicine
    • Escitalopram, 15 mg, Oral, Nightly 
  • PRN Meds
    • Lorazepam 2 mg PO

• VS per unit Protocol(24 hours)
• Observation(Q30)
• Ambulate as tolerated, encourage engagement in group activities 
• Diet: Heart Healthy- 2mg NA,300 mg Chol, <75 mg fat
• Obtain Collateral information from therapist.
• Referral to chem dependency on discharge 

Dispo: To remain as an IP for medical and psychiatric optimization. Potential for discharge on Monday with Chem Dep appointment.