For my site evaluation I presented on the following case and the feedback on my presentation is also discussed below:
Case: A 27 y/o single, unemployed, Guyanese American male with a PPHx of Schizophrenia, Depression, Substance Use disorder (alcohol and cannabis), and one past suicide attempt (details unclear) living with his mother who was BIB/EMS activated by his mother for psych evaluation following bizarre behavior at home. Patient was bent down with his hand over his head and his fingerings covering his ears due to auditory hallucinations. The patient has been non-complaint with medications. The Patient was held in CPEP for further observation and restarted on medications.
As described above the patient was presenting with auditory hallucinations following non-compliance to his medications and he was also determined to be positive for recent cannabis use based on the results of his urine toxicology. During my evaluation my evaluator pointed out that based on the lab results that I had obtained for the patient it appeared the patient was not fully “medically cleared” and presently had medical problems that were not addressed prior to his transfer over to the CPEP unit. Based on his lab findings it appeared that the patient was also suffering from poor kidney function and had a very elevated glucose level. It is an important point to catch as this indicates a breakdown in the clearance protocols and points out the need for more care when determining whether a patient is fully medically cleared before a consult is made and the patient is brought over to another unit. Next time I will be more careful when reviewing patient charts while on my other rotation.