Tiffany Liang
Psychiatry End of Rotation H&P 2
Dr. Saint Martin
February 1, 2022

Identifying Data :

Full Name: Ms. AA
Address: Astoria, NY
Date of Birth: 2/11/1997
Age: 24 yo
Date & Time: January 2, 2022 12:30 PM
Location: Elmhurst Hospital, Queens NY
Religion: None
Source of Information: Self
Reliability: Good
Source of Referral: Self – called 911 for EMS

Chief Complaint : “Tried to commit suicide,” 3 days ago.

History of Present Illness
24 yo Persian female patient, single, domiciled alone in an apartment, with a PMHx of hypothryoidism and a PPHx of obsessive-compulsive disorder, anxiety, and major depressive disorder presents to the inpatient psych unit for a suicide attempt (1/2/2022). Patient activated BIBEMS (Brought In By Emergency Medical Services) after feeling dizzy and regretting her decision. Patient states she took 8 xanax pills with alcohol due to “feeling lonely & depressed” following a sexual trauma incident on 12/25/2021. After repeatedly expressing she did not want to have sex, a male individual whom she met on a dating app continued his advances and forced to have oral and vaginal intercourse. She explains that her family was unsupportive and did not express concern after she opened up to them about the incident. After the phone call, she felt increasing discomfort and loneliness that prompted her to ingest 8 xanax pills and 4 shots of tequila. Patient states that she drinks alcohol in social settings and has tried cannabis in the past but did not enjoy it. Denies other drug use and is a non-smoker. Patient has one previous psychiatric admission due to a suicide attempt in overdosing on pills (2017). She has participated in outpatient therapy with a therapist and psychiatrist since her suicide attempt in 2017. Denies current heart palpitations, shortness of breath, dizziness, nausea, vomiting, diarrhea, or constipation. Denies recent travels.

Vitals

Blood Pressure
130/85

Height – 5’10
Weight – 160 lbs

BMI – 23

Past Medical History
Obsessive Compulsive Disorder
Anxiety
Major Depressive Disorder
Immunizations – Up to date; flu vaccine yearly

Past Surgical History
N/A

Medications
Currently On :
Levothyroxine (Synthroid) 50 mcg PO 1x daily
Bupropion (Wellbutrin) 75 mg PO 2x daily
Fluvoxamine (Luvox) 150 mg PO 1x daily, divided into 2 doses
Alprazolam (Xanax) 0.25 mg PO 1x daily

Allergies
No allergies to foods or medications

Family History
Mother – Aged 60 yo, alive
Father – Aged 62 yo, alive

Brother – Aged 22, alive
Sister – Aged 27, alive
No Children, Never married
Denies family medical history of cancer or respiratory complications

Social History
Patient is a single 24 yo female who lives by herself in an apartment in Astoria. Patient is Persian-American and English speaking only. She is currently unemployed and was expected to start a Masters program in January 2022.

Habits : Patient drinks socially (2-3 standard drinks 1x per week) and has tried marijuana in the past but did not enjoy it. Denies use of other drugs or smoking cigarettes.

Travel : Denies recent travel.

Diet : Patient eats a diet containing mostly carbs such as sandwiches and pasta. Patient admits she could be incorporating more fruits and vegetables into her diet.

Exercise : Patient maintains a sedentary lifestyle. She states that she does not work out and that her physical activity comes from daily steps around the house.

Sexual History : Heterosexual, never married and no current partners. States she has had 3 partners in the past year for casual hook-ups that did not lead to intercourse. The only exception was her sexual trauma experience on 12/25/2025. Denies history of sexually transmitted diseases.

MENTAL STATUS

ORIENTATION – Good. Patient is able to identify self, day of the week, location in hospital, and reason for coming to the hospital.

APPEARANCE – Good. Patient presents with clean attire and good hygiene but with disheveled hair. Patient’s hair is loosely pulled back in a ponytail.

ATTITUDE – Cooperative. Patient readily participates and is eager to answer interview questions.

BEHAVIOR – Within normal limits. Patient does not present with tics, twitches, or abnormal muscle movements.

EYE CONTACT – Good. Patient maintains strong eye contact throughout the interview and is engaged during conversation.

SPEECH – Patient speaks at a normal volume and rhythm. Speech sometimes speeds up when excited but is within normal limits.

MOOD – Hopeful and optimistic. Patient expresses eagerness to make changes in her life to prevent another episode of suicidal ideation and action.

AFFECT – Full & Congruent. Patient appears with a full range of emotions. She is excited for discharge.

THOUGHT PROCESS – Linear. Patient presents with a clear, coherent, and organized thought process.

THOUGHT CONTENT – Some anxiety, patient was worried about who would be able to see her psychiatric admission records in the future. Patient did not express any delusions or verbal/auditory hallucinations. Patient also did not demonstrate obsessions or phobias.

SUICIDAL IDEATION – Denied by patient.

VIOLENT IDEATION – Denied by patient.

PERCEPTUAL DISTURBANCES – None elicited. Patient does not present with any visual or auditory hallucinations.

INSIGHT – Fair. Patient understands severity of a suicide attempt but does not appear to have a solid grasp of the work she needs to put in during outpatient treatment. Patient expressed worry over release of psychiatric records when obtaining botox.

JUDGMENT – Fair. Patient exhibits positive attitude and motivation in preventing a suicide attempt in the future. However, the patient does not appear to prioritize her goals after inpatient admission. She is concerned about receiving botox and visiting Florida.

IMPULSE CONTROL – Good. Patient did not exhibit drug-seeking, sexual, or inappropriately aggressive behaviors during admission stay.

Review of Systems

General – Female patient appears optimistic of future and eager to be discharged. Does not appear to be anxious, depressed, or in acute distress. Patient appears well-groomed, well-nourished, and active while seated. Denies loss of appetite, generalized weakness/fatigue, fever, chills, night sweats.

Skin, hair, nails – Denies excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus.

Head – Denies headaches, vertigo, head trauma, coma, or fractures.

Eyes – Denies other visual disturbances, lacrimation, photophobia, or pruritus. Wears glasses. Last eye exam was 1 year ago.

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction, or epistaxis.

Mouth/throat – Denies bleeding gums, use of dentures, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam 1 year ago – normal.

Neck – Denies localized swelling/lumps. Denies stiffness or decreased range of motion.

Breast – Denies lumps, pain, or discharge.

Pulmonary System – Denies shortness of breath that is alleviated with a daily inhaler. Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular System – Denies chest pain, palpitations, edema/swelling of ankles or feet, syncope.

Gastrointestinal System – Denies nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, dysphagia, pyrosis, abdominal pain, diarrhea, hemorrhoids, constipation, rectal bleeding.

Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain.

Menstrual and Obstetrical — Menarche age 12. Last menstrual cycle took place 3 weeks ago. Denies abnormal vaginal discharge color, amount, odor, or itching.

G = 0, T = 0, P = 0, A = 0, L = 0
Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory.

Musculoskeletal System – Denies muscle weakness and slowness. Dull aching, swelling, and stiffness on the right hip. Denies redness or sharp pains.

Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.

Hematological System – Denies anemia, ecchymosis, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine System – Hypothyroidism since 18 years old. Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating or goiter.

Psychiatric – History of depression, anxiety, and OCD that began 6 years ago. Sees a therapist and psychiatrist regularly. Denies current suicidal ideation. Denies homicidal thoughts.

Assessment & Plan
24 year old female with no significant past medical history and past psychiatric history of obsessive compulsive disorder, anxiety, and depression presents to the inpatient psychiatric unit for suicide attempt. Her exam was positive for pill overdose, alcohol use, sexual trauma, depressed mood, and attention-seeking behavior.

Problem List :
Xanax overdose
Alcohol Misuse
Sexual Trauma
Depressed Mood

D/Dx :

Major Depressive Disorder – Patient has a history of major depressive disorder that could have been exacerabated by her recent sexual trauma and lack of social and familial support.

Borderline Personality Disorder – Patient has a history of several psychiatric disorders that may have evolved into borderline personality disorder. Patient has a history of unstable mood and relationships. She also demonstrates fear of abandonment and loneliness and recently attempted suicide.

Acute Stress Disorder – Patient recently experienced sexual trauma that caused signficant distress. The time length is under one month and does not yet meet the criteria for post-traumatic stress disorder.

Histrionic Disorder – Patient may present with attention-seeking behavior as she attempted suicide after receiving little support from her family. Patient was observed to be very sociable in the inpatient psychiatric unit and eager to talk to providers to share her experiences.

Malingering – This diagnosis is possible but least likely. As the patient was admitted to the hospital for a short period of time, it is unlikely we obtained the entire picture of her thought processes and motivations. There is a potential that she wanted to delay starting school or receive attention from family members.

Plan :
Admit the patient for inpatient psychiatric monitoring. Initiate medical and psychotherapy treatment to stabilize the patient’s mood. Ensure that the patient does not have access to objects or substances that may be used for suicidal attempts.

Drug Test
Perform a 10 – panel urine toxicology to monitor for potential drugs that patient may be abusing or used during suicide attempt

EKG & Labs
Rule out cardiac abnormalities from xanax and alcohol overdose
Obtain CBC, CMP labs to evaluate drug levels and any blood or electrolyte abnormalities

Medications
Initiate Emtricitabine-Tenofovir Disoproxil Fumarate (Truvada) 200-300 mg tablet for HIV prophylaxis
Have patient start on Lorazepam (Ativan) 2 mg PO daily for anxiety
Continue patient’s current psychiatric medications Bupropion (Wellbutrin) 75 mg and Fluvoxamine (Luvox) 150 mg
Observe patient for the next 2 – 3 days for improvement in anxiety and depression

Psychotherapy
Have patient engage in individual and group therapy to explore and navigate through experience of sexual trauma and loneliness
Explore healthier coping mechanisms with patient

General Lifestyle Management
Encourage patient to continue outpatient treatment with therapist and psychiatrist to develop healthier coping mechanisms and goal-setting
Recommend to the patient to refrain from marijuana, drugs, or alcohol
Encourage patient to develop a strong social support system such as a trustworthy friend circle or group therapy sessions