History

Identifying Data:

Full Name: Mr. E

Address: Not Disclosed

Age: 12

Date & time: 10/14/2021 1:00 PM

Location: QHC EELOS

Religion: Not disclosed

Source of Information: Self & School Social Worker

Reliability: Reliable

Source of Referral: School Social Worker

Mode of Transport: EMS

Chief Complaint: Cutting, suicidal ideation

History of Present Illness:

12 year old boy in 6^th grade with no known past medical history, BIBEMS for psychiatric evaluation after school social worker noticed cuts on bilateral forearms. Patient accompanied by school social worker who assisted as historian. Social worker reports last Friday she noticed 2-3 scratches on 1 arm, today she noticed more scratches on both arms and became concerned. She reported the patient’s story was consistent when asked, he reported it was due to playing with the cat. Social worker noted patient is doing well in school with no behavioral problems and she is unaware of any previous mental health diagnosis or history of self harm or suicide attempt.

Patient reports scratches are due to playing with his mother’s cat, denies cutting himself. Patient reports he sleeps well, eats well, doing well in school and enjoys math. Denies feeling sad or anxious, denies being bullied at school. Denies domestic violence, depression, self injury behavior, suicidal ideations, suicidal attempts, auditory/visual hallucinations. Patient has been following with therapist for 5 years for adjustment to parent’s divorce. Attempted to contact therapist with no answer, message was left with request to call back. Patient lives with father, aunt, paternal grandparents and 2 teenage sisters Monday-Thursday, lives with Mother and 2 sisters Friday-Sunday. Patient has extremely superficial fine scratches to both forearms that possibly could be consistent with a scratch from cat.

Father contacted via telephone for collateral information. Father reports patient has not been depressed and he did not notice any self injury behavior. Father denies history of self injury or suicide attempt. Father reports patient was upset that he could not walk home from school and is instead being picked up by his grandmother, otherwise no problems at home. Father also noted that 2 years ago patient had scratches on arms from play fighting with his 2 sisters. Father reports that the patient is well supervised at home and is not currently at risk to harm self and does not believe patient intentionally cut self. Father reports he will make outpatient appointment with Therapist ASAP.

Upon evaluation in EELOS, patient appears alert, oriented, calm and cooperative. With good eye contact with constricted affect and neutral mood, rational, polite with no behavioral disturbances, non psychotic and not floridly depressed and logical thought process. Pt has adequate insight, judgment and impulse control. Pt is currently non psychotic and is not floridly depressed and denies suicidal ideation and suicidal behavior at not an imminent risk to self and others and can be discharged from the EELOS to home and will be monitored at home by family. Dad will make an appt with therapist for follow up and continued treatment for adjustment related treatment due to divorce.

Past Medical History:

Denies any significant medical history

Past Surgical History:

Denies surgical history

Denies appendectomy, cholecystectomy, cataracts

Medications:

Denies medications or recent changes in medications

No vitamins, herbal teas or supplements

Allergies:

NKDA

No known environmental allergies

No known food allergies, no shellfish or seafood allergies

Family History:

Denies significant family history of psych disorders

Social History:

See above

Mr. E is a 12 year old boy living in a house with father, aunt, paternal grandparents and 2 teenage sisters Monday-Thursday, and apartment with Mother and 2 sisters Friday-Sunday.

Habits- Denies alcohol, drug, or tobacco use. Denies caffeine consumption

Sleep-Sleeps 8-10 hours per night

Review of Systems

General-See HPI

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, moles/rashes, pruritus or changes in hair distribution.

Head – Denies headache, vertigo, head trauma, LOC, fracture

Pulmonary system – Denies dyspnea, SOB, cough, hemoptysis, orthopnea

Cardiovascular system – Denies CP, palpitations, HTN, irregular heartbeat, known murmur

Gastrointestinal system- Denies abdominal pain, diarrhea, jaundice, changes in bowel habits, flank pain, dysphagia, pyrosis, flatulence, eructation,

Genitourinary – Dysuria. Denies frequency, hematuria, incontinence, nocturia

Nervous –Denies seizures, loss of consciousness, sensory disturbances, ataxia

Hematological system –Denies easy bruising, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

 Psychiatric – See HPI

Vital Signs

HR 91

BP 120/75

O2Sat 97%

Temp 98.2 F oral

Physical Exam

General: Comfortable appearing boy, well groomed, in no acute distress. Alert and oriented x3. Appears stated age.

Skin: extremely superficial fine excoriations on bilateral forearms, no lacerations, no active bleeding

Hair: average quantity and distribution

Chest – Respirations unlabored, no use of accessory muscles noted.

MENTAL STATUS EXAM

General

1. Appearance: Mr. E is a medium height and thin young male with brown hair. Appears well groomed, appripriately dressed in hospital gown with good hygiene and maintained good eye contact throughout the evaluation.

2. Behavior and Psychomotor Activity: No delayed verbal response time or decreased motor activity

3. Attitude Towards Examiner: Cooperated with the examiner and established rapport in about five minutes.

Sensorium and Cognition

1. Alertness and Consciousness: Mr. E remained alert and consciousness for the entirety of the evaluation

2. Orientation: Oriented to the time of day, the place of the exam and the date.

3. Concentration and Attention: Demonstrated satisfactory attention and was alert. He gave relevant responses to questions.

4. Capacity to Read and Write: Displayed average reading ability.

5. Abstract Thinking: He showed fair ability to abstract. He understood why he was brought to the emergency room and why the school social worker was concerned about the cuts on his arms.

6. Memory: Remote and recent memory were unimpaired.

7. Fund of Information and Knowledge: Intellectual performance was average and

consistent with age and level of education

Mood and Affect

1. Mood: His mood was neutral and appropriate for a 12 year old

2. Affect: His affect was constricted and appropriate for his age

3. Appropriateness: His mood and affect were consistent with the topics discussed. He did not exhibit labile emotions, angry outbursts, or uncontrollable crying.

Motor

1. Speech: His speech pattern was normal in rate and soft tone

2. Eye Contact: He made adequate eye contact.

3. Body Movements: He had no extremity tremors or facial tics.

Reasoning and Control

1. Impulse Control: Denies suicidal ideation or plan and denies homicidal ideation.

2. Judgment: Mr. E had no paranoia, bizarre delusions, auditory or visual hallucinations.

3. Insight: Displayed fair insight into her psychiatric condition based on acceptance of help and cooperation with school social worker and outpatient therapist

Differential Diagnosis:

1. Nonsuicidal self-injury (NSSI): NSSI is defined as the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned, includes behaviors such as cutting, burning, biting and scratching skin. The patient’s cuts are reportedly not deliberate or self inflicted based on history obtained from both patient and family members. The patient reports the cuts are from playing with the cat which is not consistent with a diagnosis of NSSI
2. Adjustment Disorder: Patient follows with therapist for past 5 years since his parents’ divorce. Manifestations: distress out of proportion to severity of stressor, impairment in social functioning, depressed mood, anxiety. Usually resolves within 6 months of stressor. Patient does not exhibit any of these symptoms, patient and social worker reported no impairment in social function, no depression or anxiety. Patient’s presentation is most likely benign scratches from playing with cat. Scratches are very superficial and not organized. Child is not acutely depressed or psychotic, has no active suicidal ideations or history of suicidal ideation or suicide attempts or history of self cutting. Patient has support at home from many family members and support at school.
3. Generalized Anxiety Disorder : Patient follows with therapist to help adjust to parents’ divorce. Father reports patient was concerned about being unable to walk home from school alone and the need to walk with his grandmother however the patient does not express excessive concern about everyday life and is not exhibiting features consistent with generalized anxiety. Generalized anxiety disorder typically present with excessive worries about everyday life, household chores, finances, and job performance lasting for at least 6 months.
4. Oppositional defiant disorder: Oppositional defiant disorder is characterized by a pervasive pattern of disobedience, anger, stubbornness, hostility and defiant behavior toward authority figures. Law violation is not a common trait. It also cannot be diagnosed if a child matches criteria for conduct disorder. The patient’s behavior is not consistent with ODD as he is not displaying any of the diagnostic criteria, he is doing well in school, is sociable, he is not hostile, and is not defiant toward family members, school social worker/other school staff, or with provider during evaluation in EELOS

Upon evaluation in EELOS patient appears alert, oriented, calm and cooperative. With good eye contact with constricted affect and neutral mood, rational, polite with no behavioral disturbances, non psychotic and not floridly depressed and logical. Pt has adequate insight, judgment and impulse control. Pt is currently non psychotic and is not floridly depressed and denies suicidal ideation and suicidal behavior and at this time is not an imminent risk to self and others and can be discharged from the EELOS.

• Patient is stable and no intervention is required at this time
• Family involved with discharge plan and father feels safe with discharge home at this time
• Recommended increased supervision and monitoring at home by family, discussed with father, aunt, and grandmother. Family understands and agrees to monitor at home for self injury behavior and any new cuts as well as for signs of depression and anxiety.
• Father will make an appt with therapist for follow up and continued treatment for adjustment related treatment due to divorce. Patient has standing therapy appointment via telephone weekly and meets in person with therapist once per month.
• Patient voiced understanding of concerns of provider and social worker and reports he will continue to be compliant with his therapy and will tell an adult if he feels urge to cut himself or if feels suicidal.