Inpatient Intake Note

Summary

• 34 y/o M (Marcus Vance, DOB: 12/05/1990, MRN: 492-881-04) admitted voluntarily on 24/10/2024 at 09:15 America/Chicago for acute manic episode with psychotic features. Pt stabilizing on milieu therapy and re-initiated mood stabilizers.
• Strengths: Supportive sister, college educated, voluntary admission. Difficulties: Medication non-adherence, poor insight during mania, cannabis use. Objectives: Mood stabilization, sleep restoration, medication compliance.

Chief Complaint

• "I haven't slept in five days because I'm decoding the financial market algorithms."

History of Present Illness (HPI)

• Mr. Vance is a 34-year-old male with a history of Bipolar I Disorder who began experiencing progressively decreased need for sleep, racing thoughts, and grandiosity approximately two weeks prior to admission. Over the past five days, his symptoms escalated to include total insomnia, pressured speech, and paranoid delusions that federal agencies are monitoring his computer.
• Symptoms were precipitated by abrupt discontinuation of his outpatient lithium regimen three weeks ago due to feeling "cured" and experiencing mild hand tremors, compounded by increased stress at his accounting job.
• His sister attempted to manage him at home by removing his car keys and encouraging sleep aids, which failed, prompting her to bring him to the ED after he attempted to wire $15,000 to a fictional startup.

Psychiatric History

• Diagnosed with Bipolar I Disorder at age 24. Two prior inpatient hospitalizations (2016, 2020) for manic episodes; responded well to lithium and olanzapine. Sees outpatient psychiatrist Dr. Alan Grant intermittently.
• History of passive suicidal ideation during a depressive episode in 2018. Denies history of suicide attempts or non-suicidal self-injury (NSSI).

Medications

• Current Medications: lithium carbonate (Eskalith®) 900 mg PO QHS for mood stabilization (non-adherent x 3 weeks).
• Possessed Medications: Half-empty bottle of lithium carbonate 300 mg capsules secured in hospital pharmacy.
• Medication Access: No financial or insurance barriers; stopped medication by choice.
• Inpatient Medications:
  • PRN: lorazepam (Ativan®) 2 mg PO/IM Q6H PRN severe agitation/anxiety; olanzapine (Zyprexa®) 5 mg PO Q6H PRN agitation.
  • STAT: olanzapine (Zyprexa®) 10 mg IM and lorazepam (Ativan®) 2 mg IM administered in ED on 24/10/2024 at 03:30 America/Chicago for acute agitation.
  • Medication Refusal: Refused morning dose of lithium carbonate on 24/10/2024 at 09:30, stating it "blocks his mental clarity," but agreed to take evening dose after psychoeducation.

Substance Use

• Alcohol: 3-4 beers per weekend for 10 years; binged 6 beers two nights ago. Tobacco: Denies. Cannabis: Smokes 1 g daily for the past 2 years to "slow down thoughts."
• Cravings/Withdrawal: Denies current cravings or withdrawal symptoms; CIWA-Ar score 0.

Pain History

• Denies acute or chronic pain (0/10 on numeric rating scale).

Drug Screen Result

• UDS positive for THC and benzodiazepines (received lorazepam in ED); negative for amphetamines, cocaine, opiates, barbiturates, and PCP. BAL < 10 mg/dL.

Social History

• Lives alone in a rented apartment in Chicago, IL. Single, no children. Employed full-time as a CPA, currently on medical leave. Sister (Elena Vance) lives locally and is primary support.

Family History

• Maternal uncle with Bipolar I Disorder; father with hypertension and AUD.

Legal History (Guardianship, Conservatorship, Representation, etc.)

• Retains own legal guardianship; no conservatorship. Sister is listed as healthcare proxy.
• Arrested once in 2016 for disorderly conduct during first manic episode; charges dropped. No current legal issues.

Trauma/Abuse History

• Denies history of physical, sexual, or severe emotional abuse in childhood or adulthood.
• Strong family support network serves as a protective factor; no current trauma-related concerns.

Sleep

• Slept 0-1 hours per night for the 5 days preceding admission. Slept 4 hours last night on unit following STAT medication.

Functioning Status

• Independent in basic ADLs, though hygiene has declined over the past week. IADLs impaired acutely due to reckless financial spending and inability to work.

Disposition

• Emotionally labile and irritable, with poor insight into illness severity. Expresses reluctance to stay inpatient but agrees to remain for a few days to "rest" before discharging home to outpatient care.

Aggression

• Verbally hostile and loud in the ED when prevented from leaving; no physical aggression toward staff or property. Calm on unit currently.

Review of Systems (ROS)

• ADHD: Distractible and hyperactive (secondary to mania); no childhood history of ADHD.
• Anti-Sociality: Denies antisocial traits or lack of remorse.
• Anxiety: Endorses mild restlessness and worry regarding his financial algorithms.
• Autism: Denies history or symptoms of ASD.
• Depression: Denies current low mood, anhedonia, or hopelessness.
• Eating Disorder: Decreased appetite over the past week due to high energy; no body image concerns or purging.
• Mania: Endorses elevated/irritable mood, grandiosity, decreased need for sleep, pressured speech, flight of ideas, and reckless spending.
• OCD: Denies obsessions or compulsions.
• Personality Disorder: No baseline maladaptive personality traits reported when euthymic.
• Psychosis: Endorses paranoid delusions (government surveillance) and grandiose delusions; denies AH/VH.
• Trauma: Denies nightmares, flashbacks, or hypervigilance.

Mental Status Exam

• Appearance: Disheveled, wearing mismatched clothing, malodorous. Behavior: Psychomotor agitation, pacing, intrusive but redirectable. Speech: Pressured, loud, rapid. Mood: "Fantastic." Affect: Labile, expansive, irritable when challenged. Thought Process: Flight of ideas, tangential. Thought Content: Grandiose and paranoid delusions; denies SI/HI. Perceptions: Denies AH/VH, does not appear to be responding to internal stimuli. Cognition: Alert, oriented x4. Insight: Poor. Judgment: Severely impaired.

Tests and Scores

• YMRS (Young Mania Rating Scale): 34 (severe mania). PHQ-9: 2. GAD-7: 6. C-SSRS: 0 (no suicidal ideation or behavior).

Allergies

• Penicillin (hives).

Review of Systems (General ROS)

• Constitutional: Endorses fatigue masked by high energy; denies fever or chills.
• Neurological: Denies headache, dizziness, or current tremors.
• Cardiovascular/Respiratory/GI: Denies chest pain, SOB, nausea, vomiting, or diarrhea.

Physical Exam

• General: Well-nourished male in no acute physical distress. HEENT: Normocephalic, atraumatic, PERRLA, EOMI. Cardiovascular: Tachycardic, regular rhythm, no murmurs. Respiratory: Lungs clear to auscultation bilaterally. Abdomen: Soft, non-tender, non-distended. Neurological: Cranial nerves II-XII intact, gait steady, no resting or intention tremor noted today. Skin: Warm, dry, intact, no evidence of self-harm.

Vital Signs

• BP: 138/86 mmHg, HR: 104 bpm, RR: 18 breaths/min, Temp: 37.1 °C, SpO2: 99 % on room air.

Level of Observation and Precautions

• Q15min checks. Elopement precautions due to ambivalence about hospitalization. Standard unit safety precautions.

Physical Safety Risks

• Low fall risk (Morse Fall Scale: 10). No physical mobility limitations.

Safety Assessment

• Low acute risk for suicide or self-harm (denies SI, no history of attempts). Moderate risk for inadvertent self-harm or vulnerability due to severe manic impulsivity, grandiosity, and poor judgment. Denies HI.
• Protective factors include supportive sister, stable housing, employment, and no access to firearms. Safety plan includes inpatient stabilization, elopement precautions, and family involvement prior to discharge.

Assessment

• 34 y/o M with Bipolar I Disorder presenting with an acute manic episode with mood-congruent psychotic features, precipitated by medication non-adherence. Requires inpatient psychiatric stabilization due to severe functional impairment, reckless behaviors, psychosis, and inability to care for self safely in the community.

DSM-5-TR Codes

• F31.2 Bipolar I disorder, current or most recent episode manic, with psychotic features.
• F12.10 Cannabis use disorder, mild.

Plan

• Admit to inpatient psychiatric unit on voluntary status. Re-initiate lithium and start standing atypical antipsychotic for acute mania and psychosis. Obtain baseline labs (BMP, CBC, TSH, lipid panel, HbA1c, trough lithium level). Engage in group therapy when less disruptive.
• Treatment Changes: Restart lithium carbonate (Eskalith®) 600 mg PO QHS (titrate to 900 mg PO QHS as tolerated) and initiate olanzapine (Zyprexa®) 10 mg PO QHS.

Follow-Up Email

• Dear Elena, Thank you for accompanying Marcus to the hospital today. With his consent, I am updating you that he has been admitted to our inpatient unit for stabilization of his mood and sleep. We have restarted his medications and he is resting comfortably. Visiting hours are daily from 16:00 to 18:00. Please contact the unit nursing station at (312) 555-0192 with any questions.

Billing Codes

• ICD-10: F31.2, F12.10, Z91.19 (Patient's noncompliance with other medical treatment and regimen). CPT: 99223 (Initial hospital inpatient care, high MDM).

To-Dos

• Order morning lab draw for 25/10/2024 at 06:00 (CBC, BMP, TSH, A1c, Lipids). Request outpatient records from Dr. Alan Grant. Schedule family meeting with sister prior to discharge.
• Attend daily medication education group. Maintain sleep log with nursing staff. Complete relapse prevention worksheet prior to discharge.