Chief Complaint: “My grandma called mobile crisis on me because I wasn’t responding to her while I was in the shower yesterday” 

History of Present Illness:

            28 y/o M unemployed, domiciled in Queens with grandmother w/ PPHx Bipolar Disorder Type I admitted to psychiatric unit for reports of mania and grandiosity on behalf of his mother and grandmother. On approach (04/29), patient was reading a book in his room, agreed to be interviewed in the conference room. When asked about reason behind admission, patient stated that he was in the shower “playing [his] music really loud and singing along” when his grandmother knocked on the door. He did not acknowledge her, stating “I was having ‘me’ time” and when he exited the bathroom, social work and NYPD were in the hallway. During interview patient described himself as a “a jack of all trades”, reporting that he plays baseball, basketball, is a rapper, and invests in NFTs, cryptocurrency, and stocks. Endorsed that prior to admission he had been awake for “48 hours straight, no sleep” and that he could feel his energy being manipulated during this time. Patient explained that he is a “high-energy” individual and that this sensation can be overpowering if he does not have an outlet for his energy. Patient also endorsed gambling problem, claiming that the most he spent in one day was $7,000 which compromised ~35% of his savings at the time. States that he purchases items that “accumulate value over time” because “the value of the dollar is going down”. Denies visual or auditory hallucinations, paranoia, abnormal external or internal sensation, or beliefs that he has a special relationship with God/other higher beings.

Treatment team reached out to mother at xxx-xxx-xxxx. She reports that patient was hospitalized x1 month in August at New York Presbyterian. States that upon discharge patient agreed to remain compliant with long-acting Risperidone-Depakote but did not attend follow-up appointments. Mother noticed decline in behavior in October when patient got into physical altercation with a street vendor and had his jaw broken. Since then, mother states that patient has been claiming that “God nominated him to be king”, has begun shoplifting under the impression that store items are free, and has been giving away his clothes. She reports that he no longer cares for his appearance as he walks around with dirty clothes, “hair all over the place”, and raps loudly to himself. Additionally, states that prior to admission to CPEP patient was volatile, claiming that “God is going to make [him] kill people”. Mother is aware of patient’s marijuana use but unsure if he is consuming other illicit drugs.

Mother also stated that patient is unable to maintain employment because once he feels tired of working, he will not show up to work. Mother confirmed that patient was in the Air Force in 2015/2016 where he completed basic training and was on active duty; as per mother, he would “attend once a month”. During this time, he began playing baseball for leisure, not at a professional level as the patient endorsed during interview on 04/29/2024. Mother reports that upon return from the military in 2018/2019, he was given LSD by his high-school friends and was “never the same since then”; was told by medical professional that the LSD “may have triggered something in his brain”. Mother feels that patient is “nowhere near” baseline and feels he is not ready to be discharged anytime soon. States he called her yesterday asking her to sneak marijuana onto the unit and called grandmother asking her about where “they” had placed the bomb on the unit.

During subsequent interview (05/01), patient was less talkative and exhibited more linear thought process. Patient is more goal-oriented, stating that upon discharge he is going to seek employment to finish his child psych degree at Queensborough Community College. Patient also intends to remain on medication.

            Upon evaluation, patient is AOx3, cooperative, engaged with good eye contact. Speech is non-pressured but tangential with normal volume. Has no evidence of self-harm and denies SI/HI/AH/VH. Patient has poor judgement, and but fair insight. Has good impulse control. Patient should be counseled on importance of adherence to medication to prevent relapse of symptoms.          

Past Medical History:

Bipolar Disorder Type I

Past Surgical History:

No known past surgical history

Medications:

Risperidone and Valproic Acid (non-compliant) for management of Bipolar Disorder Type I

Allergies:

NKDA

No known environmental allergies

No known food allergies

Family History:

Grandmother alive and well, resides in Queens: PMHx HTN, T2DM, HLD

Mother alive and well, resides in Queens: No PMHx

Social History:

Living Situation – Z.L. is a 28 y/o M residing in Queens with his grandmother.

Highest Level of Education – 1 year childhood psych in undergrad at Kingsborough Community College 

Habits – Smokes marijuana every day (3 joints), drinks socially; denies use of crack, cocaine, opioids

Travel – no recent travel

Appetite – no changes in appetite

Sleep – sleeps 6-8 hours everyday

Occupation – currently unemployed but invests in NFTs, cryptocurrency, and stocks

Past arrest/incarceration history – none

Review of Systems:

General: Denies fever, chills, night sweats, fatigue

Skin, hair, nails: Denies discolorations, moles/rashes, changes in hair distribution

Head: Denies headache, vertigo, head trauma, unconsciousness

Eyes: Denies use of contacts, glasses, visual disturbances, fatigue, lacrimation, photophobia

Ears: Denies hearing loss, tinnitus, discharge, earache

Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, PND

Cardiovascular system: Denies chest pain, HTN, palpitations, edema/swelling of ankles or feet

Gastrointestinal system: Reports allergies to apples.Denies changes in appetite, nausea, or vomiting.

Endocrine System: Denies polyuria, polydipsia, polyphagia, or heat/cold intolerance

Nervous System: Denies seizures, or loss consciousness.

Psychiatric: Reports history bipolar disorder type I. Denies feelings of helpless/hopelessness/SI, lack of interest in usual activities, or h/o anxiety, obsessive/compulsive disorder.

Physical:

Vital Signs:       

Temperature: 98.1

O2 Sat: 100%

Height: 70 inches

Weight: 179 lbs

BMI: 25.0 kg/m2

Respiratory Rate: 18

Heart Rate: 66

Blood Pressure: 119/50

Mental Status Exam (04/29)

General:

1. Appearance: Patient is seated comfortably and is not in acute distress. His hygienic state was clean. Well nourished.
2. Behavior: No apparent tics, tremors, or fasciculations.
3. Attitude Toward Examiner: Patient was superficially cooperative with examiner but minimized severity of symptoms. Answering questions appropriately when prompted, but required reorienting during first interview as he was tangential. Displaying respect towards staff.

Sensorium & Cognition:

1. Alertness and Consciousness: Patient was conscious and alert throughout interview
2. Orientation: Patient oriented to place, date, and time of interview
3. Concentration and Attention: Displayed satisfactory attention. Gave relevant responses to questions
4. Capacity to Read and Write: Patient was able to properly sign name and read
5. Abstract Thinking: Concrete; able to implement deductive reasoning
6. Memory: Remote and recent memory appear intact
7. Fund of Information and Knowledge: Patient’s intellectual performance consistent with level of education

Mood and Affect:

1. Mood: “Great!”
2. Affect: Happy
3. Appropriateness: Mood and affect were congruent with discussed topics

Motor:

1. Speech: Non-pressured but tangential with normal volume
2. Eye Contact: Fair
3. Body Movements: Body posture and movement is appropriate without psychomotor abnormalities noticed

Reasoning and Control:

1. Thought Content: Delusional, exhibiting grandiosity.
2. Impulse Control: Good
3. Judgement: Poor. Patient refused to follow-up with long-acting medication after discharge from New York Presbyterian which led to relapse in symptoms.
4. Insight: Fair

Risk Assessment:

1. Wish to be dead – Have you wished you were dead or wished you could go to sleep and not wake up? No
2. Suicidal thoughts – Have you had any thoughts of killing yourself? No

—If YES to 2, ask questions 3, 4, 5 and 6. If NO to 2, go directly to question 6—

3. Suicidal thoughts with method – Have you been thinking about how you might kill yourself? No
4. Suicidal intent – Have you had these thoughts and had some intention of acting on them or do you have some intention of acting on them after you leave the hospital? No
5. Suicide Intent – Have you started to work out or worked the details of how to kill yourself either for a while you were here in the hospital or for after you leave the hospital? Do you intend to carry out this plan? No
6. Suicide behavior – While you were here in the hospital, have you done anything, started to do anything, or prepared to do anything to end your life? No

Risk to self? No

Risk to others? No

DDx:

1. Bipolar Disorder Type I; Current Manic Episode: Bipolar Disorder Type I is characterized by manic episodes lasting at least seven days or manic episodes that are severe enough to warrant hospital admission. To meet a diagnosis of Bipolar Disorder Type I, a patient must exhibit three or more of the following: inflated self-esteem/grandiosity, decreased need for sleep, being more talkative than usual, distractibility, increase in goal-directed activity, or excessive involvement in activities that have a high potential for painful consequences.  Our patient meets four of the criteria, making it likely that he is experiencing a manic episode s/t medication non-adherence for management of his bipolar 1 disorder. 

• Substance Induced Mood Disorder: Substance Induced Mood Disorders are depressive, anxious, psychotic, or manic symptoms that occur secondary to substance abuse. Our patient endorsed that he engages in marijuana use daily, specifically reporting that he “smokes about three blunts a day”. According to the Alcohol and Drug Abuse Institute “marijuana use disorders are more prevalent among persons with bipolar spectrum disorders compared to the general population or persons with any mental illness” and can lead to prolonged or worsened manic episodes in this patient population. Since the patient is not on any medication to manage his bipolar 1 disorder, it is possible that his marijuana use induced an episode of mania.

• Delusional Disorder: Delusional Disorder is a psychiatric condition in which a patient has ≥ 1 plausible delusion for ≥ 1 month. During this time, functionality is not impacted, and the patient is able carry on with their regular activities of daily living. The patient expressed that he is “a jack of all trades” and that “his credentials are all stacked up”, implying that he can get a job in whichever field he chooses because of his experiences as a baseball/basketball player, Air Force veteran, rapper, and investor. He exhibited an inflated sense of self-worth but ultimately admitted that he “is on government assistance”. His perceptions and reality are incongruent, perhaps qualifying him for delusional disorder.

• Narcissistic Personality Disorder: Narcissistic personality disorder is a cluster B personality disorder characterized by a pervasive pattern of grandiosity/entitlement in which patients exhibit a need for admiration and lack empathy for others. A diagnosis is established once a patient is followed up with for an extended period. Based on the inflated sense of self-worth, there may be some narcissistic qualities that the patient has which warrant further investigation.

Assessment:      

28 y/o M unemployed, domiciled in Queens with grandmother w/ PMHx Bipolar Disorder Type I admitted to psychiatric unit for reports of mania and grandiosity on behalf of his mother and grandmother. During first interview, patient was cooperative, engaged with good eye contact. He was admitted to AB11 on Risperidone/Valproic Acid four days prior from CPEP (which may have mitigated some of his manic symptoms by the time the treatment team became involved). Patient is scheduled to be discharged early the following week pending his behavior on unit.

Diagnosis – Bipolar Disorder Type I; Current Manic Episode

Disposition –  Stabilize patient on Risperidone and Valproic Acid, discuss importance of adhering to medication

Plan:

• Routine observation
• Labs: Urine Toxicology, Valproic Acid Levels, CBC w/o differential, CMP, Hepatic/Renal Function Test, Lipid Panel, TSH, QuantiFERON, COVID-19
• Scheduled Medications:
  • Risperidone 1 mg PO BID
  • Valproic Acid 500 mg PO BID SCH
• PRN Medications:
  • Haloperidol and Lorazepam
• Individual and group therapy