-Chief Complaint: “I have a crazy boyfriend”
History of Present Illness:
Per EHR review: “This is a 48 years old white Hispanic male with a past medical*HIV, chronic hepatitis C, depression, history of lumbar surgery, and history of seizures. Patient noncompliant with his medication. Patient was brought to the ER by the police because he got arrested due to domestic violence and patient in police car started hitting his head on the windshield and by police patient started having seizure-like activity for like 10 seconds. Patient also have seizures while he was in the ER. Patient seen by neurology. He did receive loading dose of Keppra. His medication was changed for a Vimpat 100 mg twice a day loading dose was given. And by neurology recommendation patient should be admitted to the hospital for observation for seizures. Patient postictal, but answer the question. Denies chest pain palpitations, denies any abdominal pain, nausea, vomiting, fever or chills.”
C-L psychiatry is consulted for management of depression.
Patient was seen and evaluated at bedside, accompanied by corrections officers. AAOx3, calm and cooperative. Patient reports that he got into a domestic dispute with his partner of 5 years in which he ended up getting arrested. Patient reports that he has had multiple physical altercations with his partner and his partner has a restraining order against him; he reports officer told him to come to the car and put his hands on the hood and he refused and began running. Patient is complaining of severe depression, helplessness, hopeless, low self- worth, poor sleep, poor appetite and passive SI. Patient reports he has no clear plan, but his life is not worth living if he has to go on like this. Patient has been non-compliant with psychotropic medications for the past year and reports not being able to remember any of the medications that he has taken in the past. Patient is amenable to starting an anti-depressant and following up in the community upon discharge from jail.
-Diagnoses: MDD, Cocaine Use Disorder, Alcohol Use Disorder, Marijuana Use Disorder, Nicotine Use Disorder
-Past Hospitalizations: multiple
-Outpatient: non-compliant
-ECT: no
-Psychiatric Medications: per chart- Cymbalta 20mg PO BID
-Past suicide attempts: reports x’s3, last attempt 1 year ago via hanging, reports he received care at Aventura Hospital
-Past violence: yes, multiple arrest for violent behavior
Past Substance Use history:
-Substances: hx of alcohol use- denies current use and cannot quantify previous amounts
hx of marijuana use- denies current use, however DAU +
hx of nicotine use- denies current use
hx of crack cocaine use- denies current use
-Past Marchman Act: denies
-Past Detox/Rehabilitation: denies
-AA/NA Participation: none
-Past Medical Complications: as per chart review
Family History:
Grandmother- unknown mental illness
Past Medical History:
-Medical diagnoses: reviewed
-Surgeries: reviewed
-Allergies: iodine
Social History:
-Born and raised: New Jersey
-Relationship Status: Single
-Children: none
-Education: high-school
-Employment: disabled
-Living situation: alone
-Hx of trauma: Yes, IPV
-Orientation: Ox3
-Appearance and Behavior: 48 y/o man, appears stated age, disheveled and unkempt, shackled to bed, cooperative
-Motor/Gait: no abnormal movements
-Eye Contact: good
-Speech: coherent
-Mood: “I’m very depressed”
-Affect: dysphoric
-Thought Process: tangential
-Thought Content: pre-occupied with arrest and partner
-Perceptual disturbances: no a/v/t hallucinations illicited
-Suicidal thoughts/Intent/Plan: passive death wishes
-Homicidal thoughts/Intent/Plan: denies
-Insight: limited
-Judgement: limited
-Attention: good
-Concentration: good
-Memory: impaired
-Language: English
-Fund of knowledge: baseline for level of education
Diagnoses
MDD, recurrent, by hx
Cannabis Use Disorder
Alcohol Use Disorder, by hx
Nicotine Use Disorder
Abrasion of scalp, initial encounter (S00.01XA)
Unspecified convulsions (R56.9)
End of Diagnoses List
Psychiatric Consult Recommendations:
Medication recommendations:
Start Effexor 37.5mg PO daily- depression, anxiety and chronic pain
Zyprexa 5mg IM q6hrs PRN- severe agitation that impedes medical care.
Labs/Imaging recommendations:
reviewed
qtc 428
dau + cannabis
Safety:
-At risk of harm to self or others: No
-Needs 1:1 sitter: No
-Requires video monitoring: No
-Baker Act status: None
-Marchman act status: No
Precautions:
-Fall risk: No
-Seizure: Yes
-Elopement: Yes
-Suicide: No
-Substance use withdrawal: Yes
-Delirium precautions: No
Other consults recommended:
-Social work assistance? Yes, safe transport to TGK jail psychiatric unit.
-Other recommended consults? No
Disposition:
Does not meet criteria for inpatient psychiatry hospitalization or involuntary hold. Discharge plan as per primary team.Patient is psychiatrically clear to be discharged to jail.
