Patient Name: Locke, Alexandra
Patient DOB: 09/11/2005
Admission Date: January 15, 2030
Room: TW221B
Evaluating Provider: Dr. George Williamson
Psychiatric Evaluation
Identifying Information:
The patient is a 24-year-old Preschool teacher. An unmarried Caucasian woman, without children, living alone, brought into the Emergency Room in acute distress and suffering from intense delusions. Patient was admitted involuntarily.
Chief Complaint:
The patient was found in her old apartment by the new tenets in mass hysterics refusing to move from or leave the property. Extremely confused and distressed the patient asked repeatedly for an unknown doctor.
History of Present Illness:
Pertinent history in record: X
During assessment: Patient describes their mood as stable. Patient expresses extreme belief in their own sanity.
Patients self-esteem appears fair, no reported feelings of excessive guilt, no reported anhedonia, reports insomnia, does not report change in appetite, does not report libido disturbances, reports feelings of hyperactivity and listlessness, reported instances of memory loss.
Patient does not report pressured speech, or euphoria. Patient does exhibit agitation. Patient exhibits excessive fears, panic attacks, increased activity, and risk-taking behaviors. Patient exhibits hallucinations, delusions, and obsessions. Patient's activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain. Patient does not report symptoms of a characterological nature.
Patient currently denies suicidal ideation, denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.
Past Psychiatric History:
Previous psychiatric diagnoses: none reported.
Describes course of illness.
Previous medication trials: none reported.
Safety concerns:
History of Violence to Self: none reported
History of Violence to Others: none reported
Mental health treatment history discussed:
History of outpatient treatment: not reported
Previous psychiatric hospitalizations: not reported
Prior substance abuse treatment: not reported
Trauma history: Client does not report history of trauma outside of her delusions including abuse or domestic violence.
Substance Use: Client denies use or dependence on nicotine/tobacco products.
Client does not report abuse of or dependence on ETOH, and other illicit drugs.
Past Medical History:
Medical history: Denies cardiac, respiratory, endocrine and neurological issues, including history head injury.
Patient denies history of chronic infection, including MRSA, TB, HIV and Hep C.
Surgical history no surgical history reported
Medications:
See Page 4.
Allergies:
NKDFA.
Family Psychiatric History:
No reported knowledge of family history of psychiatric issues -
No reported knowledge of family history of substance use issues -
Psychosocial History:
Occupational History: Preschool Teacher. Denies military service.
Education history: Doctorate in Education
Developmental History: no significant details reported.
Legal History: no reported/known of legal issues, no reported/known conservator or guardian.
Spiritual/Cultural Considerations: none reported.
Assessment & Diagnoses:
Dx: Acute Hysteria
Dx: Paranoia
Dx: Schizophrenia
Informed Consent:
Patient the does not ability/capacity to consent for their own safety. The patient appears to be unresponsive to psychiatric medications and appears unable to understand the need for medications and unwilling to maintain adherent.
Reviewed potential risks & benefits, Black Box warnings, and alternatives including declining treatment.
Expected Length of Stay:
Indefinite
Impression & Recommendations:
Patient is found to be unstable and has questionable control of behavior. Patient likely poses a high risk to self and a high risk to others at this time.
Patient abnormal perceptions and appear to be responding to internal stimuli.
Safety Risk: Due to high risk an isolation room is necessary
DX: No changes to current medication, as listed in chart, at this time
Health & Wellness:
Follow-up: Patient deferred to designated care team as needed
50% time spent counseling/coordination of care.
Visit lasted 210 minutes
Williamson, Doctor of Psychiatry
Date: January 15, 2030 Time: 16:35