Race: African American Subjective: CC (Chief Complaint): Suicide attempt. History of Present Illness (HPI): M.K. is a 31-year-old African American male brought to the emergency department by his sister after a failed suicide attempt. M.K.’s sister reports that she found M.K. lying on the floor unconscious, with an empty pack of pesticides next to him.

 
Comprehensive Psychiatric Evaluation-31-year-old male
Patient Initials: M.K.

Age: 31 years

Gender: Male

Race: African American

Subjective:

CC (Chief Complaint): Suicide attempt.

History of Present Illness (HPI): M.K. is a 31-year-old African American male brought to the emergency department by his sister after a failed suicide attempt. M.K.’s sister reports that she found M.K. lying on the floor unconscious, with an empty pack of pesticides next to him. She highlights that M.K. was unresponsive; therefore, she rushed him to the hospital emergency unit. M.K.’s sister narrates that she began noticing changes in M.K.’s mood and behavior three months ago when he lost his job and broke up with his girlfriend. The two events occurred in the same week; since then, M.K. has seemed hopeless and does not sleep. M.K. has mentioned to a few family members that he is ready to die. He has gone to the extent of explaining how he would like to be buried. M.K. received emergency care since he was unconscious and unresponsive.

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Past Psychiatric History: M.K. was first diagnosed with major depressive disorder one month ago. He is monitored closely by a caregiver during the day. In the evening and night, he is monitored by his sister. He was hospitalized for monitoring once one month ago after a failed suicide attempt. His current treatment plan for major depressive disorder involves non-pharmacological therapy through psychotherapy. He has not been prescribed any medication, as his progress with psychotherapy has been observed. He currently visits his psychiatrist once a week.

Substance Use History: M.K. reports that he smokes about one pack of cigarettes every two weeks and occasionally drinks alcohol. He describes his intake of alcohol as being “a social drinker.”

Family Psychiatric/Substance Use History: M.K.’s mother has had a history of depression and suicidal ideation since she was a teenager. She, however, has successfully managed her condition by being compliant with her treatment plan. M.K. is not aware of any mental health problems within the extended family. Notably, M.K. describes his father as an occasional drinker of alcohol and his sister as a staunch Christian who uses no recreational drugs.

Social History: M.K. was born in New York and was brought up by his father and mother. He is the last born of two children. His elder sister is 39 years old. M.K. lives in a three-bedroom apartment with his sister. He is divorced, and his girlfriend broke up with him three months ago. M.K. has a daughter who lives with his ex-wife in another city. He holds a master’s in economics and worked as a lecturer at a nearby university. Losing his job was traumatizing since he enjoys teaching and believes in the impact of empowering the younger generations. He is currently unemployed. M.K. is a good citizen who respects the law and has never had any legal history apart from his divorce trial. Before his major depression, he enjoyed playing golf with his friends and colleagues.

Past Medical History (PMH): M.K. was diagnosed with asthma when he was five years old, which he manages using oral prednisone. He was diagnosed with a major depressive disorder one month ago. His immunization status is up to date. He received two doses of the AstraZeneca vaccine for COVID-19 in August and September 2021.

Current Medications: Prednisone 5mg BD PRN.

Allergies: No known drug allergy. Lactose intolerance.

Reproductive history: Heterosexual.
ROS:
General: Reports daytime sleepiness and headache. Denies chills, fever, day sweats, fatigue, weight loss, or weight gain.

HEENT/Neck: Reports rhinorrhea and blurred vision. Denies oral, hearing, and dental problems.

Skin: Denies rashes and itching.

Cardiovascular: Denies chest pains, lightheadedness, numb extremities, paroxysmal nocturnal dyspnea, leg edema, slow wound healing, palpitations, arrhythmias, dyspnea, slow wound healing, or orthopnea.

Respiratory: Reports cough and difficulty breathing. Denies choking when swallowing, shortness of breath, holding breath during sleep, wheezing, or sputum production.

Gastrointestinal: Reports diarrhea, abdominal pain, vomiting, hypersalivation, and nausea. Denies indigestion, heartburn, choking during sleep, loss of appetite, acid reflux, constipation, or difficulty swallowing.

Genitourinary: Denies urinary incontinence, painful urination, decreased stream, frequent urination, dribbling, and blood in the urine.

Neurological: Reports loss of consciousness, headache, and confusion. Denies changes in memory, memory loss, seizures, difficulty balancing, numbness, tingling sensation, spells of blindness,  or dizziness.

Musculoskeletal: Reports tremors. Denies stiffness and muscle, joint, and back pain.

Hematologic: Denies easy bruising, exposure to HIV, swollen glands, anemia, and bleeding problems.

Lymphatics: Denies swollen lymph nodes or splenectomy.

Endocrinology: Denies weight gain, weight loss, hair loss, hot flashes, and frequent urination.

Psychiatric: Positive history of major depressive disorder. Reports a history of suicidal thoughts and ideation. M.K. has been brought to the hospital after a failed suicide attempt. He is currently undergoing psychotherapy for major depressive disorder.
Objective:
Physical Exam:

Vital signs: BP 89/59 mmHg, HR-80 bpm, SPO2- 97% on room air, Temp 97.2, RR-16 bpm, Height- 5’8, Weight- 163lbs, BMI 24.7.

General: The patient appears confused and disoriented. He is not fully aware of his surroundings. He is hygienic and well-dressed.

HEENT: Clear or nasopharynx, PERRLA, normocephalic head, miosis.

Neck: Neck has normal symmetry, no palpable lymph nodes, a full range of motion, and normal length.

Respiratory: No tenderness or palpable mass, no chest deformities, faint breath sounds without wheezing.

Heart/Peripheral Vascular: Normal heart size, normal heart rate, normal heart location, no murmurs, and normal rhythm. Normal extremities.

Abdomen: Abdominal pain. The liver and spleen are of normal size, consistency, and tenderness.

Genital/Rectal: This exam was not conducted.

Lymphatic: No swollen lymph nodes.

Musculoskeletal: Symmetric muscle development. Muscle power of 5/5 on extremities. No deformities or swelling on joints.

Neurological:  Intact deep tendon reflexes and cranial nerves.

Psychiatric: He is confused, disoriented, and unaware of the context.

Skin: His skin tone is appropriate to his ethnicity.
Diagnostic results:
Complete blood count: To test RBC levels to determine the extent of organophosphate poisoning.

Substance and alcohol screening: To rule out drug-induced depression symptoms.

RBC AChE blood test: Recommended and blood drawn before pralidoxime administration to determine organophosphate poisoning. Conducted after treatment to determine response to therapy (Robb & Baker, 2022).