Elizabeth Katz

PA-S York College

Source and reliability: Mr. D, 31-year-old African American male, reliable historian

CC: “I want to kill myself”

HPI

Mr. D a 31 y.o. African American male, domiciled with family, unemployed, PPHx of depression and substance abuse, PMH HIV+ followed at Elmhurst ID clinic, BIBEMS activated by group members at Arms Acres where he is currently undergoing intensive outpatient drug rehabilitation for suicidal ideation. Upon re-evaluation this morning, the pt is resting comfortably in his bed is calm, cooperative, goal and future oriented. He reports that on Tuesday or Wednesday of this week (7/16/19 or 7/17/19) he went to the LIRR station at Kew Gardens with the intention of jumping in front of a train, but states that he didn’t go through with  it because he “thought it would hurt too much” and if it didn’t work he would be in a worse situation than he currently is. He endorses a 9-year history of methamphetamine use but denies other illicit drug or alcohol use, with multiple trips involving “dark emotions” where he “felt like angels and god were telling me to kill myself because I am gay”. Of note, he reports multiple suicidal gestures, one in 2013 when he was close to drinking household cleaner and multiple attempts to overdose on methamphetamine which “just made me crazier”. The pt states that he has been taking Paroxetine CR 37.5mg since 2010 and was recently placed on 300mg Wellbutrin qd by his psychiatrist Dr. Borg at Arms Acres. Additionally, he reports sadness stemming from the fact that he has never been in a relationship, feeling alone and rejected by the gay community. At this time he is aware that he has a problem and expresses interest in outpatient LGBTQ psychiatric services and a suicide help group.

His mother, Lisa Coleman (718-526-0207) was provided as collateral, but was not available by phone, a voice message was left.  He reports trying to do things that “make me happy” like going to the beach or concerts of artists that he enjoys which he reports having tickets for in August. Currently, he denies suicidal or homicidal ideations, auditory or visual hallucinations and expresses a strong interest in outpatient services. At present, the pt does not present an acute harm to self and others and will be discharged with outpatient follow up.

PPHx

Major Depressive Disorder (2010)

Substance abuse (2010)

PMH

HIV+

PSH

Non contributory

Medications

Paroxetine CR 37.5mg qd

Wellbutrin 300mg qd

Abacavir-Dolutegravir-Lamivudine 600-50-300mg qd

Allergies

KNDA

Family Hx

Denies family history of psychiatric conditions or substance use

Social Hx

Pt is currently domiciled with his grandmother, mother and brother. He is unemployed and admits to methamphetamine use, but denies other illicit drug or alcohol use. He states that he is homosexual, identifes as male and is not in a sexual relationship at this time. He denies recent travel.

ROS

Constitutional: reports regular appetite. Denies weight loss/gain weakness, fever, chills.

HEENT:

Denies headaches or head trauma

Eyes: no recent changes in vision, photophobia, pt wears glasses last visit with optometrist Jan 2017

Ears: hearing intact

Nose: no obvious deformities, no epistaxis

Mouth and throat: no ulceration, hx of candidiasis, last dental visit July 2016

Neck: no adenopathy, localized swelling or stiffness

Respiratory: No SOB, cough, wheezing, hemoptysis

Cardiac: no recent chest pain, palpitations, edema of hands or feet, syncope, known murmur

Vascular: no hx of claudication, gangrene, DVT, aneurysm

GI: denies abdominal pain, N/V, change in bowel habits or BRBPR

GU: denies urinary frequency and urgency, dysuria, polyuria, hematuria, or nocturia

Sexual: homosexual, last sexual encounter 3 months ago, HIV+, unknown hx of other STIs

Hematological: no known blood or clotting disorders

Rheumatic: no hx of gout, rheumatic arthritis, or lupus

Dermatological: no rash

PE(items italicized not performed)

VS: BP 118/78 right arm, sitting position; pulse 76 regular; O₂sat 100% room air; respirations 14/min; temp 98.1°F oral; weight 200lbs

Patient is alert and oriented x 3, in no apparent distress, casually groomed and dressed appears stated age

HEENT: normocephalic atraumatic

Eyes: sclera and conjunctiva clear, EOMs full, PERRLA

Neck: trachea midline, carotids 2+ b/l, no adenopathy

Heart: regular rate and rhythm, no heaves, gallops, murmurs

Lungs: clear to ausculation bilaterally, no retractions, wheezes, ronchi, or consolidation

Abdomen: soft, nontender to palpation, BS+,no CVA tenderness

Extremities: no edema or tenderness in LE b/l, distal pulses intact, ROM intact b/l

Skin: moist, good turgor, cap refill < 2 sec, no obvious rash or scars noted

Nuero: cranial nerves intact, sensory and motor intact b/l, cerebellar reflexes intact, gait steady

Mental Status Exam

GENERAL

• Appearance: Mr. D is of medium height, is an overweight black male with glasses. He has no apparent scars on his face or arms. He appears well-groomed with casual dress.
• Behavior and psychomotor activity: Mr. D was tearful at times during the interview, psychomotor functioning was appropriate.
• Attitude towards examiner: Mr. D is cooperative and pleasant with the interviewer.

SENSORIUM AND COGNITION

• Alertness and orientation: Mr. D was alert and oriented to person, place, time and situation.
• Concentration and attention: attentive throughout the interview and provided relevant responses to questions.
• Capacity to read and write: Mr. D had a fair ability to read and write.
• Abstract thinking: Mr. D. possessed adequate abstract thinking. He was able to use appropriate proverbs as well as metaphors when speaking with the interviewer. He was able to perform simple calculations in the form of serial 7s up to 8 calculations with some hesitation.
• Memory: recent and remote memory were intact.
• Fund of information and knowledge: intellectual performance was appropriate for the level of education attained (high school). He possessed a basic understanding of current events.

MOOD AND AFFECT

• Mood: sad but with renewed desire to seek psychiatric and substance dependence services
• Affect: constricted
• Appropriateness: mood and affect were congruent with the topics discussed. He did not exhibit labile emotions, angry outbursts, or uncontrollable crying.

MOTOR

• Speech: moderate tone and quality
• Eye contact: good eye contact was maintained throughout the interview
• Body movements: no tics or fasiculations were observed. Body movements were appropriate.

REASONING AND CONTROL

• Impulse control: poor impulse control as indicated by methamphetamine abuse and suicidal ideation
• Judgment: currently denies paranoia, delusions, auditory or visual hallucinations
• Insight: At this time, Mr. D has fair insight into his psychiatric condition and the need to remain compliant with his psychiatric medication as well as follow up with outpatient psychiatric and chemical dependence services.

Diagnoses

AXIS I — Major depressive disorder, Substance use disorder

AXIS II — none

AXIS III — HIV+

AXIS IV — unemployment

Formulation 

Mr. D a 31 y.o. African American male, domiciled with family, unemployed, PPHx of depression and substance abuse, PMH HIV+ followed at Elmhurst ID clinic, BIBEMS activated by group members at Arms Acres where he is currently undergoing intensive outpatient drug rehabilitation for suicidal ideation. Upon re-evaluation this morning, the pt is resting comfortably in his bed is calm, cooperative, goal and future oriented. Currently, he denies suicidal or homicidal ideations, auditory or visual hallucinations and expresses a strong interest in outpatient services. At present, the pt does not present an acute harm to self and others and will be discharged with outpatient follow up.

Plan

• Discharge with outpatient follow up tomorrow at 10:00am (pt is given appointment – through social worker)
• Continue paroxetine CR 37.5mg qd
• Continue wellbutrin 300mg qd
• Referral for outpatient chemical dependence program provided through social worker

Differential diagnoses

• Substance-induced depressive disorder
• Persistent depressive disorder
• Bipolar II
• Hypothyroidism