Daniela Arias Rodriguez

Psychiatry Rotation H&P 2

Name: Mr. D

Sex: Male

Race: White

Date: 12/1/20

Location: Elmhurst Hospital, Queens NY

DOB: XX/XX/2000

Source of referral: Chart review and patient.

CC: Mr. D was brought by EMS (activated by mother) due to suicidal ideations, restless and tremors. 

Mr. D is a 20 y/o Jewish male domiciled with parents and two siblings, unemployed, full-time college student with medical history significant for migraine and scoliosis and psychiatric history significant for major depression disorder with psychosis, anxiety, panic attack, suicidal ideations and one suicidal attempt (stabbing, self-aborted in 2019), two CPEP visits, and one recent psychiatric admission on 10/23/20 at Elmhurst Hospital. As per chart, Pt has been struggling with anxiety and depression since middle school/beginning of high school. Depressive symptoms worsened at the beginning of college with a new onset of suicidal thoughts after having difficulty adjusting to college and failing a few courses, which led to the suicidal attempt on 12/2019. Pt was majoring in biology at Queens College. As per mother on the 2019 CPEP visit, pt started acting odd, being depressed, withdrawn from friends, disorganized and having problems concentrating, being obsessed with rabbis and religiously preoccupied for one year. After CPEP visit on 12/2019, Pt was receiving therapy at Bleuler psychotherapy center and maintained on Prozac. On 10/23/20, pt was admitted to the psychiatric unit of Elmhurst Hospital after reporting suicidal ideation by shooting himself with a gun (denied access to a gun) and expressing desires of being dead. Pt identified online learning and sexual behavior inappropriate for his religion (e.i masturbation) as his stressor. Pt expressed “I’m paying my sins and that’s why I feel this.” Upon admission to the unit, pt reported auditory hallucinations commanding him to kill himself. Pt was started on Lithium 600mg, Haldol 5mg, Clozapine, Propranolol 20 mg, Effexor 225 mg and Trazodone 50mg. Pt was discharged on 11/18/20 after improvement in symptoms and denial of auditory hallucinations. 

On 11/29/20, pt was readmitted to Elmhurst Hospital due to continued auditory hallucinations telling him to kill himself, feeling restless and having tremor after an increase in his lithium medication on 11/24/20. The night prior to admission parents found him wandering outside around 2:30 pm. As per mother, pt was complaining of sleep difficulties, blurry vision, decreased appetite and restless. Pt was observed pacing outside home and reported voices telling him to hang himself. Upon admission, pt was found with hypertension and was cleared by medicine for lithium intoxication. Pt was also given benadryl, inderal and ativan for akathisia. On assessment, pt was calm, restless with flat affect, having fair eye contact with logical speech and delayed responses, linear thought, slow movement and cooperative with the team. Pt reported auditory hallucinations (telling him “kill yourself” “you are useless”), poor sleep, feeling anxious and “unsafe” when hearing the voices, despite being constantly accompanied by family at home. Pt reported compliance with medication and attending the Elmhurst partial hospital program after discharge on 11/18/20. Upon questioning about symptoms reported on the prior discharge, pt admitted minimizing symptoms in order to be sent home and experiencing auditory hallucination upon discharge. Pt denied depression, visual hallucinations, homicidal ideations, hx of sexual, physical, emotional abuse, use of alcohol, illicit drugs or smoking. 

Past medical history: Scoliosis, migraines

Past psychiatric history: Major depressive disorder with psychosis, anxiety and panic attack. One suicidal attempt in 2019 (stabbing, self-aborted). 

Psychiatry admissions: 

Elmhurst Hospital -Two CPEP visits (Dec 2019, Oct 2020)

Elmhurst Hospital – Inpatient psychiatric (10/23/20- 11/18/20)

Surgical history: Denies

Family History: Grandmother with depression and anxiety

Allergies: Denies

Medications (prior this admission)

Lithium 600mg PO BID (increased from 300 on 11/24/20)

Haldol 5mg po Q daily

Clozapine 200mg PO q nightly

Propranolol 20 mg PO q daily

Effexor 225 mg daily 

Trazadone 50 mg nightly as needed

Social History: Mr. D is a full-time college student (dropped classes a couple months ago) majoring in biology at Queens college, who lives with his parents and two siblings. Pt is currently single, unemployed and identified himself as religious. Pt denies history of physical, emotional or sexual abuse as well as any history of alcohol, drug use or smoking. 

Review of System

Gen –  Reports difficulty sleeping, feeling anxious and restless. Denies weight loss, fever, chills, fatigue or night sweats. 

Skin, hair, nails—Denies hair loss, excessive sweating, dryness, or skin change texture.

Head— Denies headache, dizziness or recent head trauma. 

Eyes—Denies blurring vision, dryness, lacrimation, fatigue, visual disturbance or pruritus. 

Ears— Denies ear pain, discharge, hearing difficulty or tinnitus.

Nose/sinuses—Denies nose bleed, discharge or obstruction.  

Mouth/throat— Denies sore throat, bleeding gums, mouth ulcers or changes in voice. 

Neck—Denies swelling, lumps or decreased range of motion. 

Pulmonary – Denies SOB, cough, orthopnea, hemoptysis or wheezing.

CV— Denies chest pain, peripheral edema, palpitation or known heart murmur.

GI—  Denies abdominal pain, nausea, vomiting, constipation, jaundice or diarrhea. 

GU— Denies hematuria, frequency, urgency, flank pain or dysuria.

Sexual- Denies being sexually active. 

Nervous— AOx3. Denies headache, numbness, tingling, loss of consciousness or hx of seizures.

Musculoskeletal— Pt reported muscle weakness and being aware of his slow body movement, especially when walking. Denies swelling or muscle/joint pain. 

Hematological—  Denies easy bruising, anemia, hx of blood transfusion or DVT/PE.

Endocrine—Denies polyuria, diaphoresis, polydipsia, heat or cold intolerance

Psychiatric— Reports history of anxiety and depression at a young age and one suicidal attempt. Reports seeing a psychiatrist outpatient for suicidal thoughts and being compliant with medication. Denies feeling depressed at this time, having homicidal ideations, visual or tactile hallucinations. Admits auditory hallucination that tells him to kill himself. 

Mental Status Exam

General

1. Appearance: Mr. D is alert and oriented to person, time and place. Pt appears his stated age, calm, well-developed and nourished. Pt looks casually groomed and appropriately dressed with hospital clothes and a Jewish Kippah. Pt does not have visible scars, tattoos or visible physical impairment. 
2. Behavior and Psychomotor Activity: Mr. D was calm, restless and exhibiting mild tremor in hands bilaterally. Pt had an urge to stand from the seat, but was redirectible. Pt had a flat affect, fair eye contact and was cooperative. Pt exhibited psychomotor retardation. Thought was coherent and linear. Intact cognition and memory. Present of auditory hallucination (telling him “kill yourself” “you are useless”). 
3. Attitude Towards Examiner: Mr. D was very cooperative, redirectible and non-hostile to team members. Expressed remorse for minimizing symptoms on prior discharge.

Sensorium and Cognition

1. Alertness and Consciousness: Mr. D was alert and conscious during the interview.
2. Orientation: Mr. D was oriented to person, time and place.
3. Concentration and Attention: Mr. D had fair responsiveness, attention and concentration to verbal command and provided appropriate responses.
4. Capacity to Read and Write: Capacity to read and write were unimpaired. Pt asked for Jewish religious book for Shabbat observing. Pt kept himself occupied in the unit by reading books or doing puzzling games.
5. Abstract Thinking: Mr. D was able to express abstract thinking and to perform simple math calculations. 
6. Memory: Mr. D’s remote, recent and immediate were unimpaired. Pt was able to provide accurate details and dates of prior admissions. 
7. Fund of Information and Knowledge: Mr. D had a good understanding of the English language and demonstrated average intelligence.  

Mood and Affect

1. Mood: Ms. W was calm, mildly anxious, restless and cooperative. 
2. Affect: Mr. D had a flat affect congruent with mood.
3. Appropriateness: Mr. D mood and affect were consistent with the topics discussed.

Motor

1. Speech: Mr. D’s speech had a regular rhythm, normal fluency, organized and normal volume. Delayed responses.
2. Eye Contact: Mr. D made fair eye contact during the assessment. 
3. Body Movements: Mr. D exhibited psychomotor retardation as noticed by his slow gait and delayed speech. Mr. D also had mild hand tremors and purposeless movement such as an urge to stand up the chair. No facial tics, psychomotor agitation or bizarre behavior.

Reasoning and Control

1. Impulse Control: Mr. D has impaired impulse control as exhibited by his concern of responding to his auditory hallucinations.   
2. Judgment: Mr. D has a questionable judgment as noticed by his inability to perceive his auditory hallucination as unreal and his concern of responding to the voices’ commands. Denied tactile or visual hallucinations. 
3. Insight: Mr. D has a fair insight into his psychiatric disease and acknowledged the need for treatment. Pt inquired about alternative treatments such as electroconvulsive therapy.

Medical Differential Diagnosis None

Differential Diagnosis

• Schizophrenia As per diagnostic criteria, 2 or more of the positive, negative symptoms, grossly disorganized or catatonic behavior must occur for at least 6 months. All of these symptoms patients must exhibit at least hallucination, delusion or disorganized speech and must manifest for least 1 month. Mr. D has experienced auditory hallucinations since his first psychiatric admission in October 2020. Pt has exhibited negative symptoms such as asociality (socially withdrawn from friends) and impaired attention/concentration since 2019. Since his first admission in October 2020, pt has also exhibited flat affect and alogia as noted by his delayed speech and psychomotor retardation. Moreover, his symptoms have resulted in social and academic impairment, which is another diagnostic criteria for schizophrenia.

•  Major depressive disorder with psychotic features As per diagnostic criteria of major depressive disorder, pt must exhibit at least 5 of the following associated symptoms (must included either depressive mood or anhedonia): depressive mood, anhedonia, fatigue almost all day, insomnia or hypersomnia, feeling guilt or worthlessness, recurring thoughts of dead or suicide, psychomotor agitation or retardation, weigh change, decreased or increased appetite and decreased concentration and should occur for at least 2 weeks in two different instances. In major depression with psychotic features, pt must have either delusion or hallucinations. Mr. D has been struggling with depressive symptoms, suicidal attempt/ideation, insomnia, decreased concentration, feeling guilty for his actions (sexual behavior) for roughly 2-3 years and recently exhibited psychomotor retardation and auditory hallucination, which is the psychotic component of this disorder. Due to his symptoms, pt has been academically and socially impaired. It is unknown whether the patient was symptom-free for less than two months, which makes dysthymic disorder questionable. 

• Schizoaffective disorder: To meet criteria for schizoaffective disorder, pt must meet criteria for both, schizophrenia and major mood disorder. It is required that patients experience at least two week of delusion or hallucination without mood disorder symptoms. Mr. D has a history of depression since middle/high school that got aggravated during college and led to a suicidal attempt. Moreover, pt became religiously preoccupied, disorganized, and socially withdrawn. In october 2020, pt reported auditory hallucination commanding him to kill himself. During the first admission, pt reported feeling depressed and later reported the auditory hallucinations. In this last admission, pt has denied depression and has endorsed predominantly auditory hallucinations for 24 days making schizoaffective disorder a likely differential diagnosis.  

Assessment 

Mr. D is a 20 y/o Jewish male domiciled with parents (2 siblings), unemployed, previously full-time student, with psychiatric hx significant for major depression with psychosis, panic attack, anxiety, and a suicidal attempt was readmitted to the psychiatric unit due to auditory hallucinations commanding him to kill himself, feeling restless, having tremor and psychomotor retardation. Differential diagnosis include schizophrenia, major depressive disorder with psychotic features and schizoaffective disorder. 

Plan

Since Mr. D did not respond to the previous treatment of Lithium, Haldol, Clozapine, Effexor and Trazodone, the team decided to discontinue lithium and to increase the dose of clozapine to 300mg daily. On this admission, pt was started on the following medications:

Current meds 

1. Clozapine 250 mg oral nightly 
2. Clozapine 50 mg oral daily 
3. Propranolol 20 mg every 12 hrs 
4. Sennosides 17.2 mg nightly 
5. Venlafaxine 75 mg oral daily with breakfast
6. Haldol 5mg PRN

Under this regimen, Pt showed significant improvement for one week and half. Mr. D was noted to have a brighter and pleasant affect. Pt was more engaged in activity groups, and denying active auditory hallucinations. However, one week ago pt endorsed once again auditory hallucinations, anxiety and reported feeling “not well.” Currently, Pt is compliant with medication and on continuous observation. At this time, there is no plan for discharge. Clozapine was increased to 375 mg, Venlafaxine was discontinued and Benztropine was added. Team is considering electroconvulsive therapy as the last resource.

Sources: 

• Pance Prep Pearls Vol3. Pages 570, 593, 594
• https://www-uptodate-com.york.ezproxy.cuny.edu/contents/depression-in-schizophrenia?search=schizoaffective%20disorder&source=search_result&selectedTitle=3~56&usage_type=default&display_rank=3#H14699357

Article summary

Electroconvulsive Therapy and Schizophrenia: A Systematic Review. Ali SA, Mathur N, Malhotra AK, Braga RJ. Mol Neuropsychiatry. 2019 Apr;5(2):75-83. doi: 10.1159/000497376. Epub 2019 Apr 2. PMID: 31192220 

• • This is a systematic review of prospective randomized control trials published in April 2019. Although the journal is not currently indexed by medline, it was published fairly recent and addressed the topic relevant to my patient. This systematic review included a total of 27 studies (manually counted; not explicitly stated in the review). 
  • The purpose of this systematic review is to analyze available literature to determine the efficacy of electroconvulsive therapy at treating resistant schizophrenia, its impact on cognitive function, its effects on maintenance and the role of neuroimaging biomarkers to develop more accurate ECT treatment plan. 
• Method: A search was performed on PubMed of studies addressing the use of ECT in schizophrenia, which resulted in a total of 983 articles. Studies were screened to include exclusively articles addressing ECT for schizophrenia treatment.  

• A few key findings:

• In terms of efficacy, the largest study (2,074 patients) analyzing efficacy of ECT augmentation found that patients treated with ECT had lower rates of psychiatric hospitalization during the posttreatment phase. Results were more noticeable in patients treated with higher doses of clozapine or other antipsychotics. 
• A common side effect reported with ECT is cognitive impairment, which is pertinent in patients with schizophrenia, since it is a disorder associated with cognitive issues. Results on cognitive side effects were collected from a study of 20 patients diagnosed with schizophrenia who failed to respond to chlorpromazine and were randomly assigned to receive 12 sessions of real or sham ECT. Memory scale demonstrated improvement in the ECT group after 6 treatments with some decline at concluding treatment, but with recovery within one month. 
• In terms of maintenance, two studies (with 58 and 62 patients, respectively) comparing ECT alone with ECT plus medication found lower relapse rates with combination therapy as compared to either intervention alone (first study 40% versus 93%. Second study relapse free 0.86 ± 0.07, versus 0.49 ± 0.1 for medication alone). 
• In regards to ECT technique, placement of electrodes seems to affect efficacy and adverse effects. One study found that bifrontotemporal and unilateral placement of electrodes are equally effective at treating schizophrenia; however, this study did not use updated ECT standards. A recent double-blinded RCT (122  patients) found bitemporal electrode placement to be inferior to bifrontal in terms of symptoms and cognitive function in schizophrenic patients treated with ECT. 

• This systematic review concluded that ECT augmentation seems to be effective and safe in patients with severe schizophrenia disorder as observed by its minimal cognitive side effects and mild improvement in cognition. In regards to electrode placement, most available studies have utilized bilateral electrode placement; however, literature shows ambiguous results. 

Since Mr. D has responded poorly to the current regimen with Clozapine, which is the drug of choice for resistant-schizophrenia, the team is considering electroconvulsive therapy as the last resource. According to this systematic-review, ECT can be effective and safe for patients with severe schizophrenia. One of the largest studies in this review, found noticeable results with higher doses of clozapine in patients receiving ECT.

Article PDF

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End of Rotation Self-reflection: Psychiatry

• How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc).  While taking psychiatry during the didactic year, I found it to be a hard and uninteresting course. I really enjoyed learning and practicing medicine, and therefore psychiatry was a specialty I didn’t see myself practicing. However, after this rotation I have gained more respect toward the specialty and developed a better understanding of psychiatric disorders. I got to see different sides of schizophrenia going from the disorganized/paranoid patient to the calm and highly intellectual patient. I had the opportunity to meet a 30 y/o asian male with a diagnosis of schizophrenia presenting with delusions of control and somatic hallucinations (both related to the FBI) was admitted to due non-medication compliance (monitored by ACT team) regardless of being compliant with ACT appointments and exhibiting non-dangerous behavior. This patient has a bachelor in business administration, good knowledge about the mental health system and medical knowledge including antipsychotic side-effects (reason why he has refused treatment). Aside from his delusion and hallucinations, he is able to engage in pleasant conversations, and exhibit appropriate behavior; patient is well known in the unit. This patient changed my perspective of the schizophrenic patient that I had previously in mind.

• How could the knowledge I’ve gained here be applicable in other disciplines? During this rotation, I was able to learn and witness the presentation of common psychiatric disorders such as schizophrenia, major depressive disorder, substance induced-psychosis, bipolar I and borderline personality disorder. Managing these types of patients can be challenging, especially when gathering the history or they refuse treatment. During this rotation, I also got more familiar with the management of schizophrenia (drug of choice Clozapine for resistant schizophrenia), bipolar disorder, when to consider electroconvulsive therapy for patients with persistent suicidal thoughts and when to appeal for law enforcement an in-patient setting. This knowledge will be useful outside a psychiatric setting when identifying, managing and determining the disposition of these patients and how their condition can affect their medical management. I certainly gained a better understanding of evaluating patients with the mentioned conditions and performing a mental status exam. 

• What was a memorable experience that I’ll carry with me? During this rotation, I had the opportunity to observe some of the side effects of antipsychotic medications such as parkinsonism and akathisia. I observed these symptoms in a 46 y/o female with schizophrenia who initially presented with disorganized thought, grandiosity (she was an inventor of hospital devices), and persecutory delusions as well as flat affect, severe bradykinesia, restlessness and cogwheel rigidity in upper extremities. The patient was treated with Benztropine (Cogentin) and propranolol with significant improvement in a course of several days. I will certainly remember this patient, because it reminds me how extrapyramidal symptoms such as akathisia and parkinsonism look like.   

Evaluation Reflection 

For my first site evaluation, I presented a 37 y/o female domiciled in a shelter, unemployed, with psychiatric hx significant for schizophrenia, depression, psychotic disorder, multiple CPEP visits and inpatient hospitalization was admitted to the unit due bizarre and disorganized behavior. Pt has been admitted to state hospital and has failed Clozapine treatment. On assessment pt was labile with pressured speech and flight of ideas, hardly redirectable, hostile to the male team member, disorganized, illogical, paranoid, having minimal eye contact and unable to provide details about the incident at Rite Aid store. Pt was started on two antipsychotic medications (due to previous failure with Clozapine) with significant improvement, but initially was denying treatment. On our discussion, Prof. Martin touched on the HIPAA misconceptions that health professionals have when requesting consent from patients to contact collaterals. In this case, the team was not able to contact family members and obtain treatment information from the state hospital that could help in her management. 

For my second site evaluation, I presented a 20 y/o Jewish male domiciled with parents, full-time college student and unemployed with psychiatric history significant for major depression disorder with psychosis, anxiety, panic attack, suicidal ideations and one suicidal attempt (stabbing, self-aborted in 2019), two CPEP visits, and one recent psychiatric admission in Elmhurst Hospital was readmitted due to continued auditory hallucinations commanding him to kill himself, restlessness, tremor and suspected lithium intoxication. Pt was cleared by my medicine for lithium toxicity and was started on Clozapine with minimal improvement. The psychiatric team will consider electroconvulsive therapy as the last resource. In our discussion with Prof. Martin, we touch on the use and effectiveness of ECT in the patient and more appropriate diagnosis based on his presentation. Related to the case, I presented a systematic review of prospective randomized control trials published in 2019. This systematic review found that ECT augmentation seems to be effective and safe in patients with severe schizophrenia disorder as observed by its minimal cognitive side effects and mild improvement in cognition.

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