--
Hospitalist Progress Note
Author: Ethan Lee, M.D.
Date: 11/02/XX
Patient Name: James Wilson
Medical Hx: PTSD, Depression/Anxiety
Relevant Family Hx: Mother deceased d/t suicide, Father deceased d/t suicide
Home Medications: Xanax, Prozac
Patient is a 37 year old Caucasian male with a medical history of schizoaffective disorder, PTSD s/p witness to Mother’s SI attempts and eventual success 6 mo ago, psychosis disorder, anxiety, and a current everyday smoker, 3 pk/day. Pt involuntarily admitted by authorities after psychosis episode with breaking/entering a neighbor’s apartment, claiming his deceased mother was “coming to devour him”. Pt admitted and attempted to be given IV ativan for pt agitation, however pt relayed he would be compliant if we did not sedate him.
Unable to obtain a medical history for this patient d/t psychosis. EMS stated he was screaming for his daughter, but no contact information is available at this time.
Overnight Concerns: Pt sitting upright in bed, observed to be agitated and in psychosis. RN reported difficulty overnight, pt hallucinating his deceased mother “drooling over his head”. IV ativan given overnight for medical management. Pt still reports hallucinations, stating “if [he] doesn’t move, she [presumed mother] cannot follow”. Unable to redirect pt at this time. Otherwise, compliant with nursing care.
10/31/XX
Acute Psychosis
PTSD
Anxiety/Depression
Everyday Smoker
11/01/XX
Acute Psychosis
PTSD
Anxiety
Everyday Smoker
11/02/XX
Acute Psychosis
PTSD
Anxiety
Everyday Smoker
Thank you for allowing me to contribute to this patient’s care. Will be available for any and all questions and concerns.
Signed by MD, Lee, Ethan on 11/02/XX at 1533.
--
Psychology Progress Note
Author: William Chen, M.D.
Date: 11/03/XX
Patient Name: James Wilson
Medical Hx: PTSD, Depression/Anxiety
Relevant Family Hx: Mother deceased d/t suicide, Father deceased d/t suicide
Home Medications: Xanax, Prozac
This is a 37 year old male who is presenting with a sudden onset of psychosis seemingly motivated by witnessing his mother’s suicide approximately six months ago. The patient relays that he is seeing his deceased mother follow him everywhere, and if he should sleep, he says she will bring harm to him.
History of Present Illness: The patient has been receiving services under the care of Dr. Sophia Kim for the past twenty years. From my review of his documented sessions with Dr. Kim, Mr. Wilson sought out her services when he was 18 years old due to stress at home with his mother. From the records, Mr. Wilson’s mother was experiencing a similar psychosis, hallucinating that her deceased husband was trying to harm her. Mr. Wilson’s father also unfortunately committed suicide about 20 years ago, of which his mother witnessed. It seems that her fragile mental state deteriorated, and Mr. Wilson was seeking treatment for coping with both his loss of his father and his mother’s condition. Mr. Wilson, while attempting to care for his mother during her many hospitalizations and treatments, also struggled with caring for his daughter and maintaining expectations of work. Thus begins the initiating of our services.
Psychiatric History: The patient has never been hospitalized for psychiatric purposes. Outside of his therapy services, his only treatment has been at this facility. It appears that Mr. Wilson was prescribed Xanax for anxiety management a few months ago, which he states he has never utilized. After the death of his mother, and his mental state understandably deteriorated, Prozac was also added to his medication regimen. Pt also reports refusal of this medication.
Substance Abuse History:
Caffeine - Daily cup of coffee, occasional soda
Alcohol - Social use exclusively
Tobacco - Current everyday smoker. We discussed the major consequences of tobacco, and encouraged tobacco cessation.
Abuse History/Trauma/Unusual Childhood Events: Alarmingly, it appears that Mr. Wilson’s condition is recurrent in his family. Mr. Wilson’s father had hallucinations that his estranged brother (pt’s uncle) was going to “drown him”, of which was triggered by his brother’s suicide a year prior. Mr. Wilson reports that his mother attempted to get his father psychiatric help multiple times throughout his childhood, but tragically, walked in on her deceased husband, drowned in the bathtub. Shortly after, Mr. Wilson’s mother experienced the same hallucinations, stating her husband was going to suffocate her. Mr. Wilson stated that while it’s reported that his mother committed suicide by hanging 6 months ago, his inquiry of an autopsy suggested she had traumatic bruises on her wrists, arms, and neck that could not be self-inflicted. Mr. Wilson does, in some part, believe his deceased father murdered his mother…
Family Psychiatric History: Prior to any witnessed suicides/suicide attempts, there is no documented psychiatric history for Mr. Wilson’s family. Mr. Wilson himself stated that prior to his uncle’s suicide, his family had no psychiatric complications or issues.
Social History: Mr. Wilson maintained consistent employment as an environmental scientist with the Department of Natural Resources. He is divorced as of five years ago. He has a single daughter, 14 years old. However, Mr. Wilson relayed that he caused the two of them to become estranged, “for her own good”. Under inquiry, Mr. Wilson tearfully said “I cannot bear the thought of haunting her” and would not divulge under further questioning.
Mental Status Examination: The patient is alert, cooperative, yet highly anxious. He is disheveled and unkempt. He appears exhausted, and from my review, is refusing to sleep due to fear of harm from his hallucinations. He avoids eye contact, fixating on the corner of his room. His speech and intelligence are above average, goal-directed, coherent, although hurried and strenuous. Mood is fearful, and affect is anxious. The patient becomes more anxious with some of the questions during the assessment, stating “My mother wants to kill me… My father killed her… My uncle killed him, I know it…”
Prognosis and Plan of Care: Mr. Wilson is a discomforting case. I cannot discern his cognition nor a diagnosis at this time. His hallucinations are very real to him, and apparently his whole family. Aiding in his mental status would require intensive and long term treatment. As his previous family’s history was unable to be resolved, we will have to consider alternative treatments for his severe psychosis. For his own safety, sedation and transfer to a higher level of care is imperative.
Myself and my team will be rounding on Mr. Wilson frequently. Should any changes be made to his condition, please do not hesitate to reach out with concerns or questions.
Signed by MD, Chen, William on 11/02/XX at 1755.
--
Nursing Note entered by BROWN, ISABELLA on 11/03/XX at 0247.
Upon pt rounds, found patient to be standing at bedside, staring at the corner of the room. Attempted to assist patient back into bed. Pt stated “I know you think I’m confused or out of my mind, but I’m not. I see her quite clearly, and I know she’s going to hurt me. I need you to help me… I can’t stay awake much longer.” This RN relayed that she was trying to help the patient, and stating she would give him some medication to help him sleep. Pt then became angry, stating “I don’t need medications, she is haunting me! I need someone who believes what I’m saying! If I sleep, she will kill me! Why won’t you understand?” Pt then became combative, attempting to leave the facility.
This RN, Charge RN, and PCT placed pt in bed. IV ativan administered for pt agitation. Pt sleeping soundly at this time, will continue to monitor.
--
Nursing Note entered by BROWN, ISABELLA on 11/03/XX at 0342.
Code Blue initiated. Pt found covered in blood, appears to be eviscerated. MD on call notified.
--
Declaration of Death Note entered by ANDERSON, LIAM on 11/03/XX at 0402.
Patient WILSON, JAMES in room 402 pronounced deceased on November 3rd, XXXX at 0400 by Dr. LIAM ANDERSON. Patient deceased due to evisceration of bowels, cause unknown, possibly related to admitting diagnosis of psychosis. No heart sounds were auscultated, pupils were mid-dilated and fixed. No breath sounds were appreciated over either lung field. No carotid pulses were palpable. Time of death confirmed and witnessed by Nurse ISABELLA.
No family present at bedside. MD attempted contact with ex-wife Rebecca at 0358 with no response.
Patient body prepared for autopsy due to abnormal circumstances of death. Awaiting transportation arrival at this time.