Ekaterina Balash

 

07/20/2018

 

Rotation #6 psychiatry

 

Source and reliability: self, seems reliable

 

Identifying: Ms S is a 40 yo Trinidadian female, married, domiciled, unemployed

 

CC: “My brain is leaving my body and not communicating with my stomach.”

 

History of present illness:

Ms. Simon is a 40 y/o Trinidadian female, domiciled with husband and two young sons (8y/o and 1.5y/o), unemployed, with PMH of GERD, PSH of anxiety and depression, BIB husband with request to speak with psychiatric provider and also c/o headache. Patient states she came in because she feels “my brain is leaving my body and not communicating with my stomach.”  Also reports “warmness in my feet, my nervous system is going down.” Pt stated that she was evaluated in the ER this past Saturday (07/14/18) for stomach pain and workup was negative. She was seen by psychiatry and made outpatient QHC Mental Health clinic appointment for today.  Pt reports that she followed up with the neurologist 3months ago and that she was told that her symptoms are indicative of anxiety and depression, and was prescribed Zoloft 100 mg QD, which she has been compliant with for the past 3 months. Pt reports she has been taking the medication every day and has been experiencing more somatic symptoms lately.  Denies SI/HI/AH/VH.   According to  patient’s husband, at home the patient has been saying weird things and c/o tremors.  He says the patient was hyperventilating and demanding to go to the hospital.  Reports pt not sleeping at night but taking her Zoloft.

 

Past psychiatric history:

Anxiety, Depression

Past medical History:GERD

Medications: Zoloft 100 mg QD

Surgical History: none

Substance abuse history: denies

Family History: non-contributory

Allergies: none

 

Social history: married, unemployed, lives with her husband and 2 young sons. Denies alcohol, tobacco, and illicit drug use.

 

 

 

Review of Systems ( as per chart)

 

Constitutional: Negative for chills, fatigue and fever.

Respiratory: Negative for shortness of breath.

Cardiovascular: Negative for chest pain, palpitations and leg swelling.

Gastrointestinal: Positive for abdominal pain. Negative for diarrhea, nausea and vomiting.

Genitourinary: Negative for dysuria, flank pain, frequency and hematuria.

Neurological: Positive for headaches. Negative for dizziness, tremors, syncope and weakness.

Psychiatric/Behavioral: Positive for dysphoric mood. Negative for hallucinations and suicidal ideas. The patient is nervous/anxious.

 

 

Physical Exam ( as per chart)

 

Vital Signs:

BP (!) 144/90  | Pulse (!) 104  | Temp 97.9 °F (36.6 °C) (Oral)  | Resp 16  | SpO2 98%

 

Constitutional: She appears well-developed and well-nourished. No distress.

HENT:

Head: Normocephalic and atraumatic.

Right Ear: External ear normal.

Left Ear: External ear normal.

Nose: Nose normal.

Eyes: Conjunctivae are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.

Neck: Normal range of motion. Neck supple.

Cardiovascular: Normal rate, regular rhythm and normal heart sounds.

No murmur heard.

Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes.

Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. There is no tenderness.

Skin: Skin is warm and dry. She is not diaphoretic.

 

MENTAL STATUS:

 

General:

1. Appearance: 40 y/o Trinidadian female with good hygiene and casually groomed. She is of average height and build.  At time of examination she appears stated age and in no apparent distress.  Patient was cooperative throughout the interview with good eye contact.
2. Behavior and Psychomotor activity: Good eye contact, appropriate psychomotor activity.
3. Attitude Towards Examiner: Cooperative throughout interview, good eye contact.

 

            Sensorium and Cognition:

1. Alertness and Consciousness: Alert, resting in seated position.
2. Orientation: Alert and oriented to person, place, time and location.
3. Concentration and Attention: Maintained good attention.
4. Capacity to Read and Write: Unable to assess.
5. Abstract Thinking: Impaired
6. Memory: Fair
7. Fund of Information and Knowledge: Average based on response to questions.

 

            Mood and Affect:

1. Mood: Anxious, Dysphoric
2. Affect: Constricted
3. Appropriateness: Mood and affect were consistent with topics discussed.

 

            Motor:

1. Speech: Pressured
2. Eye contact: Good eye contact
3. Body Movements: normal

 

            Reasoning and Control:

1. Impulse: Fair
2. Judgment: Impaired
3. Insight: Minimally aware of problems, unable to relate them to issues with self

 

 

 

 

Assessment:

Ms. Simon is a 40 y/o Trinidadian female, domiciled, unemployed, with PMH of GERD, Past psychiatric history  of anxiety and depression presents with anxious mood and somatic symptoms. ER work up didn’t reveal any physical causes. Pt is in need of further psychiatric observation and stabilization with reevaluation in the morning.

 

 

 

PLAN:

Admit to CPEP with 1:1 observation

Obtain collateral information

Labs (TSH, CBC, BMP, Urine drug panel)

Observe

Maintain safety

Re-evaluation in the morning

Upon discharge refer to outpatient mental health specialist

 

 

 

 

1. Panic attack (Panic disorder if recurrent with concerns about future attacks).Pt presented with intense fear or discomfort with the symptoms that are consistent with panic attack symptoms such as tremors, abdominal distress, paresthesia and hyperventilation.
2. Somatic symptom disorder. Pt presented with physical symptoms involving more than 1 part of the body but work up did not show any physical cause. In addition, this disorder is most common in women after 30 yo. Moreover, this patient has excessive thoughts about the seriousness of the symptoms and as a result, excessive time and energy devoted to symptoms and health concerns.
3. Illness anxiety disorder. Pt has preoccupation with fear that she has a serious undiagnosed disease. However, somatic symptoms are not usually present, and if they present they are very mild in intensity. In addition, symptoms has to present for at least 6 months.
4. Factitious disorder. This patient might intentionally falsify or exaggerate the symptoms for primary gain. In her case, the primary gain might be attention from her husband or family.
5. This patient might falsify symptoms for secondary gain ( e.g. insurance, lawsuits, food, shelter, avoidance of responsibilities or to obtain drugs)