History

Identifying Data:

71YOM

Date & Time of Encounter: 11/20/24 11am

Elmhurst MER, Psychiatry Consult

Chief Complaint: SI x 3 days

HPI:

71-year-old male with PMH of hypertension, PPH of substance use disorder in remission (crack cocaine), MDD, and SI with one previous IPP admission (unknown date and location), currently not receiving mental health care, full-time nursing assistant domiciled alone in Queens; presents to ED complaining of depressed mood and SI x 2 weeks, with worsening SI x 3 days. Pt reports reconnecting with an old friend just prior to symptom onset. He states this friend currently uses crack cocaine and Pt has been trying to help him quit. Pt believes this to be the trigger of current decompensation, saying this reconnection has “broken his spirit.” Pt reports 2-3 alcoholic drinks a week but denies all other substance use, noting he has not used crack cocaine in many years. Notes he was previously in NA but has not attended in many years. Since reconnecting with this friend, Pt has experienced decreased appetite with weight loss, decreased sleep with nightmares,  decreased interest in daily activities, and worsening suicidal ideations. Pt endorses h/o SI, but denies h/o self-harm or previous suicide attempts. He says this is the worst his SI has ever been, resulting in him calling the Suicide Hotline 2 nights ago and again last night, which triggered his visit to this ED today. He states he does not intend to act on his SI and does not currently consider himself to be a harm to himself, but does admit he has considered “pills” as a plan. Upon arrival, Pt initially complained of chest pain, but he reports now that it has since completely resolved, he denies chest pain, palpitations, SOB at this time. Pt notes he wants to reestablish outpatient psychiatric care, says he was previously receiving psychotherapy at Elmhurst Hospital but had to stop care when his insurance lapsed. He says he has been on 1 psychiatric medication in the past, but it made him feel “in limbo,” so he did not pursue further pharmacological treatment. He is not interested in pursuing further medical management. Pt denies VH, AH, HI. Denies h/o manic symptoms.

Past psychiatric history:

MDD

Anxiety disorder

SI 

Current psychiatric medications:

None

Suicide:

Pt endorses current and previous SI with ideas of a plan, but states he will not take action

Pt denies h/o suicide attempts or self-harm behaviors.

Violence:

Denies current or previous ideations or incidents.

Past medical history:

Hypertension

Non-psychiatric medications:

None

Hospitalizations:

Reports 2wk IPP in his early 30s due to severe depression, unable to obtain further details.

Allergies:

Denies any allergies.

Family history:

Denies any family history of mental illness or other diseases.

Social History

Pt is single and lives alone. He works full-time as a CNA in Far Rockaway.

He is a non-smoker. Reports social alcohol intake 2-3 drinks/wk.

He was last sexually active 8 months ago, with a male.

Mental status exam:

General

1. Appearance: Pt is of slender body habitus and appears stated age. He is casually groomed in a yellow gown. No visible scars or tattoos.
2. Psychomotor Activity: Pt had normal psychomotor activity.
3. Speech: Pt with normal rate, tone, and pressure of speech.
4. Attitude Towards Examiner: Pt cooperated with the examiner, but intermittently needed to pause the interview as he would become tearful. 

Sensorium and Cognition

1. Alertness and Orientation: A&O x 4
2. Concentration and Attention: Pt’s attention was satisfactory, he answered questions promptly and appropriately. 
3. Thought content: Pt is able to participate in dialogue and demonstrates deductive reasoning. Normal linear thought content.

Mood and Affect:

1. Mood: “down”
2. Affect: Tearful
3. Appropriateness: Pt’s range of affect correlates with his reported mood and symptoms

Motor

1. Speech: WNL
2. Eye Contact: Satisfactory
3. Body Movements: Pt had no extremity tremors or facial tics. 

Reasoning and Control

1. Impulse Control: Pt reports SI with a plan, but demonstrates impulse control seeking help 
2. Perceptions: He is not observed responding to internal stimuli.
3. Judgment: Satisfactory, Pt took appropriate action to seek help for his condition
4. Insight: Satisfactory, he is aware of his condition and history

Physical:

Vitals: 

Temp: 98.4

HR: 73bpm

Oxygen sat %: 100% RA

RR: 16

Ht: 5ft 11in

Wt: 154

BP: 139/93

Pain scale: 0/10

BMI: 21.54

General: 

Well-nourished, alert, well-groomed male that looks his stated age, with no signs of acute distress.

Eyes: Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white and non-icteric, cornea clear, conjunctiva pink.

Pulm: Normal respiratory effort

Neurological: A&Ox4 (person, place, time, situation), no cranial nerve deficit, no motor weakness, normal coordination, normal gait, 

Assessment

71-year-old male with PMH of hypertension, PPH of substance use disorder in remission (crack cocaine), MDD, and SI with one previous IPP admission (unknown date and location), currently not receiving mental health care, full-time nursing assistant domiciled alone in Queens; presents to ED complaining of depressed mood and SI x 2 weeks, with worsening SI x 3 days. Pt is not actively suicidal and does not feel he is an immediate danger to himself at this time.

DDx:

1. Adjustment disorder with suicidal ideation
   1. Patient reports an identifiable trigger of symptoms occurring 2 weeks ago, and says he was feeling stable prior to this trigger. Thus, he meets criteria for adjustment disorder.
2. Major depressive disorder with suicidal ideation
   1. Patient has a previous diagnosis of MDD secondary to h/o similar symptoms, but he says he was feeling ok prior to reconnecting with this friend, so I have a greater suspicion for adjustment disorder complicated by h/o MDD and SI.
3. Substance use disorder with suicidal ideation
   1. Although the patient reports he has not used drugs in many years, he has recently reconnected with a friend who is actively using around him. It is possible he has used, or it is possible that simply being around substances again is resulting in emotional distress.
4. Mood disorder with suicidal ideation
   1. I have lower suspicion for this given that the patient presents with isolated depressive symptoms and denies h/o manic symptoms. However, it is important to consider it as part of my differential.

Plan

• Medical clearance for CP
• Urine tox
• If tox is negative, complete safety plan and d/c to outpatient psychotherapy