Monica Benjamin
Queens Hospital Center- CPEP
7/16/20

Identifying Data:
Full Name: Ms. D
Address: Queens, NY
Age: 64
Date: 7/8/2020
Location: Psych-ER/QHC
Source of Information: Self, EMR, EMS/ NYPD
Source of Referral: Family
Mode of Transport: EMS/ NYPD

Chief complaint- anorexia and agitation
64 year old black, single female, domiciled in family home with PMH of schizoaffective disorder,
hypertension, diabetes brought in by NYPD/ EMS for violent behavior and cleared by Medical
ER. NYPD was called by family for agitation and refusal to eat/ weight loss. Patient bit an
officer’s arm and was brought in with handcuffs, reporting that she was angry with being
“kidnapped from home” by police and how she was treated by the “crooked, corrupt thirteenth
precinct.” Patient reports that the cops “looked like humans from the outside, but are diseased
animals on the inside.” Patient reports that the “medical personnel are stupid and always fail in
their treatment because they focus on medications when the real issue is the wire tapping and
the robots.” Patient reports she does not need the help of any doctors but she needs the
Marines.
When asked about suicidal ideation, she became very agitated, saying she would not eat if she
was suicidal (she was eating crackers and jam at the time) and that it was a stupid question.
Patient reports that she checks all the food to make sure it is not tampered with. Patient
refused to answer questions about home life, homicidal ideation, and hallucinations because of
paranoid delusions that the government was trying to collect information on her. Patient has
poor insight and judgement and does not believe she belongs in CPEP. Patient maintains good
eye contact and is well-groomed but is paranoid, guarded, uncooperative, tangential, and
disorganized. Patient refuses to wear a mask and refused COVID test. Last record of
medications was risperdal and abilify in 2015. According to EMR, pt was admitted for 12 days in
July 2019 and followed up at LIJ outpatient clinic until 2/2019. Unable to obtain collateral as
patient’s niece (Janet, xxx-xxx-xxxx) did not answer. Pt was sedated with 2 mg Ativan IM in the
medical ER as she was a threat to herself and others.

Past Medical History- Schizoaffective disorder, DM, HTN
Past Surgical History- Denies any past surgical history.
Medications- unable to obtain. Likely non-compliant with psychotropic medications.
Allergies- Denies any drug allergies.
Family History- Denies any known family history of psychiatric illness.
Social History- Unable to obtain significant history. According to EMR, patient lives with family
members and does not work. Pt has never been married and does not have children.

ROS- Unable to obtain ROS as patient refused to cooperate.
General- Patient family initially referred patient for weight loss as she has been refusing to eat.

Physical Exam
Vitals:
BP 105/72, right arm sitting
Pulse- 73 bpm
RR 18 breaths/min
T 97.9F
SpO2 96%

General survey: Patient is an elderly, black female and is irritable and hostile towards staff.
Patient appears malnourished and stated age of 64. Patient appears comfortable in chair and is
currently eating. AOx3.

Mental Status Exam:
General
1. Appearance: Ms. D is an older, frail African-American woman with short gray hair. She has
good hygiene and grooming and is currently wearing a clean nightgown. She appears
malnourished and has slouched posture.
2. Behavior and Psychomotor Activity: Ms. D is currently eating crackers and jam, reading all
the packaging and insisting only on eating packaged food. She is sitting in a chair and has loud
and pressured speech. Patient maintains good eye contact.
3. Attitude Towards Examiner: Ms. D appears uncooperative and guarded, not wanting to
provide any information as she is paranoid of the government collecting information on her.
She is easily agitated by questions, especially regarding suicidal ideation, and refuses to answer
other questions. She is untrusting of providers and becomes more agitated as the interview
goes on.
Sensorium and Cognition
1. Alertness and Consciousness: Ms. D is alert and her level of consciousness was consistent
throughout the interview.
2. Orientation: Ms. D was oriented to person, place of the exam, and the date. Patient
understood she was at the hospital, the date, and who she was.
3. Concentration and Attention: Ms. D had overall good concentration during the exam,
addressing the provider’s question but often refusing to answer.
4. Capacity to Read and Write: Ms. D had normal reading and writing ability.
5. Abstract Thinking: Ms. D was not able to express abstract thinking. When asked what does
the expression “don’t cry over spilled milk” mean, she said I don’t know and stop asking me
“stupid questions.”
6. Memory: Ms. D’s recent, remote, and immediate memory were intact as she was able to
recall where she lives and her niece’s name.
7. Fund of Information and Knowledge: Ms. D demonstrates below average level of
intelligence.
Mood and Affect
1. Mood: Ms. D’s mood was agitated and angry.
2. Affect: Ms. D’s affect is hostile and congruent with mood.
3. Appropriateness: Ms. D’s mood and affect reflect her paranoid delusions and mistrust of
staff.
Motor
1. Speech: Patient’s speech pattern was loud and pressured.
2. Eye Contact: Patient had good eye contact throughout exam.
3. Body Movements: Patient had no extremity tremors or facial tics.
Reasoning and Control
1. Impulse Control: Ms. D has poor impulse control as she is very hostile and previously bit a
police officer. Patient denied suicidal ideation, saying she would not be eating if she was
suicidal. Patient refused to answer regarding homicidal ideation, among other questions,
2. Judgment: Patient’s judgement is severely impaired. She believes the medical staff and
government is after her.
3. Insight: Patient has poor insight and does not believe she needs to take medication. Patient
believes she was kidnapped by the “corrupt” police and brought here.

Assessment: 64 year old black, single female, domiciled with family, with significant PMH of
schizoaffective disorder, diabetes, and hypertension, brought in by EMS/ NYPD for agitation,
anorexia, and biting a police officer. Patient is acutely psychotic, disorganized, and illogical, with
paranoid and persecutory delusions. Consistent with psychosis related to schizoaffective
disorder and non-compliance with treatment.

Plan
1. Admit to Inpatient Psychiatry for further observation and stabilization, as she is
grossly psychotic, a threat to herself and others, and has been refusing to eat at
home.
2. 1:1 observation to ensure her safety and the safety of others
3. Start patient on the following medications:
1. Risperidone 1 mg PO, twice daily for schizoaffective disorder
2. Aspirin 81 mg PO, once daily for cardioprotection
3. Lisinopril 2.5 mg PO, once daily for hypertension
4. Consult with Internal Medicine for optimal management of diabetes
5. Attempt to obtain COVID test again as criteria for admittance.
6. Obtain CBC with differential, CMP, HbA1C, Utox, RPR, TSH, lipid panel, hepatic panel,
quantiferon, ECG before admittance.
7. Haldol 5 mg and Ativan 1 mg as needed for agitation/ agression
8. Call Niece (Janet xxx-xxx-xxxx) again to attempt to obtain collateral

Differentials
1. Schizoaffective disorder- Patient has a well- documented history of schizoaffective
disorder with a 12 day admittance to Jamaica Hospital in July 2019. Patient has likely not
been compliant with medications and is exhibiting disorganized, delusional, and irritable
behavior.
2. Dementia- Patient is 64 years old and is very irritable with poor judgement. Obtain
collateral from family to assess if the patient has deteriorated over the past few months
and any worsening of her condition.
3. Antisocial Personality Disorder- Patient is violent and bit an officer and has no remorse,
believing that the officers are “corrupt” and “diseased animals.” Unlikely to be solely
antisocial personality disorder as she also exhibits delusional behavior and also likely
would have been diagnosed with the disorder earlier if present.
4. Substance use- consistent with irrational and aggravated behavior. Unlikely because of
patient’s age and no noted history of substance abuse problems. Rule out with urine
toxicology.
5. Hypoglycemia- patient is delusional and has bizarre behavior with a history of diabetes
and anorexia. Unlikely as she received medical clearance before reporting to psychiatric
ER.

Ms. D is currently a danger to herself and others as she is violent and has been refusing to eat
at home. She needs observation and stabilization of both her medical and psychiatric illnesses,
as well as ensuring adequate nutrition. Patient has been non-compliant and needs inpatient
admittance. Case discussed with attending physician.