“The voices were bothering me.”

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QUESTION

Chief complaint: Patient stated, “The voices were bothering me.”

H.A. is a 37 y/o African American male who came to the ED due to severe depression, commanding auditory hallucinations, suicidal ideations, noncompliance with medications for the past month, difficulty sleeping at night, severe anxiety and mood swing. During the interview patient stated, “I feel depressed, anxious, I can’t sleep at night, I haven’t been taking my medications for a month, I hear voices telling me to jump off a bridge, I have thoughts of wanting to hurt myself.” Patient positive for cocaine per topology reports. Every other lab normal. Has psychiatry history of schizoaffective disorder bipolar type, medical history of obesity and no surgical history reported. Denies family history of mental illness. Patient single, with no children and living with a friend now. Currently unemployed and receives monthly SSI benefits. Occasionally smokes and drinks alcohol. Denies any past legal history. Denies owning any firearms.

MENTAL STATUS EXAMINATION:
Appearance: appropriate for age stated, minimal eye contact noted, hygiene needs improvement, and fair cooperation during interview.
Psychomotor Activity: No agitation, no tremor.
Attention and Concentration: Poor
Orientation: Alert and oriented x 3.
Speech: Fast rate and mildly loud volume, pressured speech noted, and disorganized.
Affect: Flat
Mood: Depressed, anxious, guarded, hypomanic and labile.
Thought process: Disorganized with tangential thinking noted and flight of ideas.
Thought Content: Reports commanding auditory hallucinations and noted to be responding to internal stimuli. Denies visual hallucinations, denies paranoia and delusions. Positive for suicidal ideations. Denies homicidal ideations.
Intellectual Functioning: Average
Motivation for Treatments: Fair

• Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; and current psychiatric diagnosis, including differentials that were ruled out.
• Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.

Address the following:
• Subjective: What details did the patient provide regarding their personal and medical history? What are their symptoms of concern? How long have they been experiencing them, and what is the severity? How are their symptoms impacting their functioning?
• Objective: What observations did you make during the interview and review of systems?
• Assessment: What were your differential diagnoses? Provide a minimum of three (3) possible diagnoses. List them from highest to lowest priority. What was your primary diagnosis, and why? 1) Schizoaffective disorder bipolar type, (2) Cocaine Abuse. Base on the scenario add 1 more diagnosis.
• Reflection notes: What would you do differently in a similar patient evaluation?

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