Full name: C.Y
Address: Queens, NY
Date of Birth: 08/26/2002
Location: Queens Hospital Centre (CPEP)
Source of Information: Self
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
Past Psych History:
– Depression x 5 months.
Past Surgical History:
-No known drug allergy
-Allergic to shellfish and shellfish derived products
Mother – 39 and alive and well. Does not know medical hx
Father – 45 and alive. Does not know medical hx
Siblings – None
– 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.
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.
Fund of information and knowledge – Patient intellectual performance was average and consistent with level of education (Highschool)
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.
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
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.
- 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.
- Poor Social support
- Substance use (nicotine/vaping)
- Admit to CPEP and observe Q15 mins.
- Obtain labs: CBC, CMP, UA, Utox, TSH
- Start on Zoloft (Sertraline) 50 mg daily
- Recommend supportive therapy
- Counsel on the harm of vaping and nicotine use.
- CBC w/ differential: All WNL
- CMP: ALT and AST were elevated otherwise all WNL
- Blood Alcohol level: Negative (<10 mg/dl)
- Drug screen was not collected.
- Covid -19 (negative)