I presented this H&P at my second site evaluation with Dr. Saint Martin:
27 y/o Hispanic male, unemployed, domiciled with parents, with a PPHx of Bipolar Disorder BIBEMS/NYPD (not under arrest) from a bodega after exhibiting manic behavior. Patient has a history of medication non-compliance, is aware of his Bipolar diagnosis but states “I want to go home, I don’t know why I’m here.” When questioned why he’s here patient repeatedly states that he didn’t do anything, says he takes his Depakote but then later states “I’m lying I don’t take any medication.” Patient is grandiose, repeatedly states “I know everything, there’s nothing you can tell me that I don’t know.” Patient reports he doesn’t sleep and that he could be up for 60 hours at a time “sober.” Patient graduated high school and Stonybrook college, is unemployed but reportedly trades online. patient appears agitated, irritable, disorganized with poor insight and impaired judgement. Patient denies drugs or alcohol use, SI/HI or AH/VH.
Writer spoke with patient’s mother, BM (***) ***-****, who states that the patient was diagnosed with Bipolar disorder 5 years ago and has been non-compliant with his medications. Reports that patient was discharged from Zucker Hill last week and took Depakote there but since his discharge he hasn’t taken any medication. Patient reportedly has been very aggressive, spending a lot of money, hasn’t been sleeping or coming home at night and checked into a hotel. States he went to Zucker Hill because he was “lost ad aggressive” and she doesn’t know why he was discharged. Mother provided the names and numbers of his provider (NP) and social worker.
Writer spoke with the patient’s provider, RA (***) ***-****, who has had patient under her care for 3 years. States that patient was admitted to Zucker Hill on November 10th and discharged on the 24th. During his time there they administered Abilify maintena 400 mg on the 22nd and was discharged on Depakote 400 mg bid, Lamictal 25 mg bid, klonopin 0.5 mg bid, gabapentin 300 mg bid and melatonin 3 mg. She reports that patient was compliant in the hospital but upon discharge patient stopped taking his medication/wasn’t taking it properly. Since discharge from Zucker Hill patient has been excessively smoking marijuana and spending money. On Tuesday morning, November 30th, patient has called the cops at 3 am saying his parents were holding onto his car keys. The parents subsequently gave them to him, he took off, checked into a motel and went to an NYC Bodega where the cops brought him from for mania, agitation and delusional thinking. Patient had reportedly been stable before his admission to Zucker Hill when he was on AOT but since AOT graduated him he has been non-compliant with his medication and smoking marijuana. NP strongly believes if he goes back on AOT he will be motivated to be compliant with his medication and stop smoking.
Patient has a PPHx of Bipolar I Disorder (2016). Patient denies any PMHx, past surgical history, known allergies or pertinent family history. On social history, patient denies drugs or alcohol use, although collateral information shares his recent excessive marijuana use. Patient is not sleeping, can be awake for 60 hours at a time. Patient has been excessively spending money. The longest he’s held down a job for is 1 year and a half.
ROS is negative. Vital signs: BP – 101/65, Temp – 98.1 F, HR – 65, RR – 18, SpO2 – 96%, Weight – 74.8 kg/ 165 lb. PE is negative. Labs: positive for cocaine, THC. Mental status exam: Appearance – as stated age, casually groomed wearing pajamas, dark rings around his eyes, fair hygiene. Alert, no wounds or injuries. Behavior – restless, disorganized, agitated, irritable, not very cooperative with interview. No tics, tremors, psychomotor retardation or any involuntary movements. Pt does not appear internally preoccupied or responding to internal stimuli. Attitude – not giving much information, fairly uncooperative, hostile, tells the examiner “I know everything, there is nothing you can tell me that I don’t know.” Alertness and cognition – alert, stable level of consciousness. Orientation – A&O x3. Concentration and Attention – poor attention and concentration, needed to be asked questions more than once. Visuospatial Ability – normal visual perception, appropriate balance, normal gait, maintained eye contact. Capacity to read and write – average/better than average and writing ability consistent with education. Abstract thinking – poor abstract thinking, illogical thought process. Memory – intact remote memory, did not display good recent memory as he couldn’t recall what brought him to CPEP. Fund of information and knowledge – intellectual performance was average/better than average and consistent with level of education. Mood – irritable, angry and elated. Affect – labile, unstable. Appropriateness – mood and affect were congruent. Speech – speech is pressured with increased rate and volume. Eye contact – made eye contact throughout interview. Body movements – hyperexcitable, restless without any tics, rigidity or unintentional body movements. Impulse control – poor and impaired impulse control, agitated, hostile, restless, lies about medication compliance. Judgement – poor and impaired judgement, disorganized, delusional thinking, doesn’t think he did anything wrong. Insight – pt doesn’t know why he’s here, doesn’t disclose any information provided by collateral about why he was brought to hospital.
Assessment: 27 y/o Hispanic male with PPHx of Bipolar I disorder, noncompliant with medications, exhibiting manic behavior including delusional thinking and agitation. Plan: Pt is manic, impulsive and unpredictable and may be a danger to self and others. Admit to inpatient unit N3, continue current meds, Q15 min observation, psychoeducation.
Dr. Saint Martin provided great critique and offered helpful knowledge and insight into the case I presented. He helped me form differential diagnoses and expand on my thinking of differentials. He greatly contributed to my learning!
