Date: 05/05/2022

Full name: C.Y

Address: Queens, NY

Date of Birth: 08/26/2002

Location: Queens Hospital Centre (CPEP)

Religion: None

Source of Information: Self  

Reliability: Reliable 

Source of Referral: None 

Mode of Transport: EMS/school

Chief Complaint: “I said that I did not care about my life anymore” x 1 hr. 

History of Presenting Illness:

Patient is a 19 y/o Asian male with a PPH of mood disorder (HCC/Depression) and no significant PMHx who is BIB by EMS activated by his school for suicide risk. Per the patient he was caught vaping in the hallway of his school and then taken to see the school counselor. He states that during his conversation with counselor he stated, “I don’t care about my life anymore.” The counselor was concerned and called EMS. The patient states that he lives in the U.S. with his grandfather because his dad and mom were recently divorced 5 months ago, and his mother moved back to China while his dad is not currently active in his life. The patient states that he is closer to his mother and speaks with her 3x a week now that she is China, but he believes she is there seeking a new partner and does not intend to return to the U.S. He states that he does not have a close relationship with his father and his father is usually gone for months for work, so he is never around. The patient does not have any other siblings or close family members here as his parents moved to the U.S when he was only 6 years old. He states he has some friends that he spends time with, but he states he doesn’t seek help from them. The patient states that he has been feeling sad ever since his parents’ divorce and he had attempted to harm himself 4 weeks ago by making cuts on his arm. The patient states that he has spoken to a therapist and was recommended some medications which he refused to take. The patient denies any homicidal ideation, auditory or visual hallucinations. He denies any drug use such as marijuana, cocaine but admits to alcohol use but only in social settings.  

Past Medical History

– None

Past Psych History: 

– Depression x 5 months.

Past Surgical History:

– None

Medications:

– None

Allergies:

-No known drug allergy

-Allergic to shellfish and shellfish derived products 

Family History:

Mother – 39 and alive and well. Does not know medical hx  

Father – 45 and alive. Does not know medical hx 

Siblings – None 

Social history: 

– Lives alone with grandfather who is 80 y/o 

– He is in his senior year of high school (originally dropped out but went back to obtain his degree) 

– He states that his parents still support him financially even though they are not physically around.

– Admits to EtOH use but only in social settings and no more than 2 drinks/ day

– Admits to recent use of vapes (nicotine)

– Denies other/ drug use 

Review of Systems

General – denies recent weight loss or gain, loss of appetite, fever or chills

Skin hair and nails – healed bruise from cuts previously made on left arm (also noted during PE). No complaints of dry skin, or discolorations, pruritus, hair loss or open wounds

HEENT: denies headache, changes in vision or hearing, or smell. 

Pulmonary System- denies dyspnea, cough or wheezing 

Cardiovascular System- denies chest pain or palpitations, edema, syncope

Gastrointestinal system – denies abdominal pain, diarrhea, constipation

Genitourinary system – denies dysuria and hematuria 

Menstrual /obstetrical – not applicable

Nervous – denies dizziness  

Musculoskeletal – denies any weakness or difficulty with motion 

Peripheral vascular system – denies any pain in calves

Hematological – denies spontaneous bleeding

Endocrine system – denies polydipsia

Psychiatric – admits to feeling depressed and having suicidal thoughts. Denies AV hallucinations. Past interaction with mental health professional but not on medications.

Physical exam:

Vital signs: 

Using machine: BP (right arm) 124/ 86 mmHg

Pulse: 84 bpm RRR

RR: 18 breaths/min unlabored

T: 98F oral

O2 sat: 98% on room air 

BMI: Weight: 142lbs, Height: 5’11 = 19.8

Mental Status exam

General appearance: Patient is a young Asian male and appears to be in no acute distress. He is dressed appropriately, well-groomed and appears to be well nourished. 3 healed cut marks noted on the patients left forearm. 

Behavior and psychomotor feature: Normal psychomotor behavior. No tremors and maintains proper posture. Adequate verbal response. Maintains eye contact.

Attitude towards Examiner – patient is cooperative with verbal questioning and well-mannered.

Sensorium and Cognition

Alertness and consciousness: Patient is alert and non-drowsy throughout the interview.

Orientation: Patient is oriented to person, place and time.

Concentration and Attention – Patient was attentive throughout the interview and answered all questions asked appropriately in a timely fashion.

Capacity to read and write – Patient has adequate reading and writing ability as noted during admission whichs attest to level of education

Abstract Thinking – Patient has a good understanding of the phrase “Do not judge a book by its cover”

Memory – Memory appears to be intact as able to recall events leading up to this current visit and memory of mental health hx.

clarity.

Fund of information and knowledge – Patient intellectual performance was average and consistent with level of education (Highschool) 

Mood Affect

Mood – The patient appears sad and depressed.

Affect – Constricted 

Appropriateness – mood and affect were consistent with the patient presentation and chief complaint all through the interview. No angry outbursts.

Motor

Speech – Patient is soft spoken. No pressured speech. 

Eye Contact – Pt maintained good eye contact throughout interview

Body Movements –Normal. No tics or unintentional movements noted 

Reasoning and Control

Impulse control –impaired impulse control with suicidal thoughts.

Judgement – Patient has fair judgement and is aware there of his situation and the effects of his actions. No AV hallucinations.

Insight – Patient has minimal insight into his condition and the need to comply with medications

Assessment: 

19 y/o Asian male with a PPH of mood disorder (depression) and no significant PMHx is BIB by EMS activated by his school for suicide risk. Per the patient he was caught vaping and when taken to the school counselor stated that “I don’t care about my life anymore.” The patient appears in no acute distress. Upon evaluation, the patient is calm and cooperative. The Patient is to be held for further observation as he is at low risk of suicide.

Differentials:

1. Borderline personality disorder: Patients can also have feelings of dysphoria and recurrent suicidal ideation. However, it is characterized with fluctuations in mood within a single day. Depression usually has dysphoria present for most of the day and nearly every day for at least 2 weeks.

• Adjustment disorder with depressed mood: can be considered because this like unipolar depression can present with feelings of dysphoria in the context of an identifiable psychosocial stressors. Usually, it is associated with a markedly depressed mood usually in response to an identifiable psychosocial stressor. Level of distress typically exceeds what would be expected in response to the stressor. It often resolves within 6 months of resolution of the stressor. 

• Attention deficit hyperactivity disorder: can also be associated with impaired concentration, inattention.  Depressive disorders however are more characterized by symptoms such as changes in sleep and appetite and feeling of suicidality.

Problem list:

1. Depression
2. Poor Social support
3. Substance use (nicotine/vaping)

Plan:

1. Admit to CPEP and observe Q15 mins. 
2. Obtain labs: CBC, CMP, UA, Utox, TSH 
3. Start on Zoloft (Sertraline) 50 mg daily 
4. Recommend supportive therapy
5. Counsel on the harm of vaping and nicotine use.

Labs: 

1. CBC w/ differential: All WNL
2. CMP: ALT and AST were elevated otherwise all WNL 
3. Blood Alcohol level: Negative (<10 mg/dl)
4. Drug screen was not collected.
5. Covid -19 (negative)