Identifying Data:
Time: 8 PM, November 19, 2019
Name: JK
Sex: Male
Race / Nationality: Asian
Marital status: Single
Location: QHC CPEP
Source of information: Chart Review / EMS / Family Members

Chief Complaint: Catatonia

HPI:
JK is a 35-year-old male, domiciled with parents, with 1 year college, unemployed since May 2019, was driving a cab for 6 years prior to May 2019, with recent diagnosis of schizophrenia (May 2019), with one previous psychiatric admission at Hillside Hospital, BIBEMS last night with psychosis and catatonia.  Patient was recently seen with similar presentation – catatonic state, evaluated here in CPEP from 11/4/19-11/16/19 and discharged home with good response with Ativan. At time of discharge, patient noted understanding of importance of taking daily medications to prevent catatonic state. Upon arrival to CPEP, the patient was given Ativan 1mg IM for catatonia.  On CPEP admission evaluation, patient was mute, sitting in his bed in the same position (supine – staring) and unable to participate in evaluation. Dr. Redman spoke with Ms. Betty, patient’s sister at time of CPEP admission, 917-234-5678, who reported that patient had been non-compliant with medication as he reported he was “sedated.” The patient’s sister reported a gradual decline since his discharge on 11/16/19, noting he stays in the shower for hours using cold water and he reportedly goes to park and remains mostly with catatonic-like posture.  At home he reportedly sits, does not listen to music or watch TV, nor does he talk with parents or siblings.

Per chart review, patient reportedly slept through the night and maintained control throughout the night with q15 observation for safety and behavioral changes.  Patient continued to be mute and isolative with fair impulse control, remaining internally preoccupied with poor attention to his hygiene. 

Upon re-evaluation, patient remains in a catatonic state with inability to participate in re-evaluation interview.  Patient laying flat (supine) with arms at side, intermittently blinking but maintaining mute disposition. Patient exhibiting waxy flexibility with inability to answer any questions or contribute to the dialogue. 

At this time, patient requires admission for further psychiatric evaluation, observation and to restart medication due to history of noncompliance and decompensation to catatonic state. Case discussed with Dr. Fold.

Psychiatric History:
Schizophrenia with catatonia 

Trauma History:
None

Hospitalization History:
No prior medical hospitalizations.
Patient hospitalized November 2019 for medication noncompliance 11/14/19 – 11/16/19.

Substance Use History:
Denies EtOH, smoking or illicit drug use.

Family Psychiatric History:
Patient denies any family psychiatric history.

Medical History:
None

Surgical History:
None

Current Residence:
Domiciled with parents.

Employment:
Unemployed – former cab driver

Medications:
Patient noncompliant with medication.  

Allergies:
NKDA
No known environmental allergies

ROS:
General: unable to assess as patient is in a catatonic state.
Skin, hair, and nails: unable to assess as patient is in a catatonic state.
Head: unable to assess as patient is in a catatonic state.
Eyes: unable to assess as patient is in a catatonic state.
Ears: unable to assess as patient is in a catatonic state.
Nose/sinuses: unable to assess as patient is in a catatonic state.
Mouth and Throat: unable to assess as patient is in a catatonic state.
Neck: unable to assess as patient is in a catatonic state.
Breast: unable to assess as patient is in a catatonic state.
Pulmonary System: unable to assess as patient is in a catatonic state.
Cardiovascular: unable to assess as patient is in a catatonic state.
Gastrointestinal system: unable to assess as patient is in a catatonic state.
Nervous: unable to assess as patient is in a catatonic state.
Musculoskeletal System: unable to assess as patient is in a catatonic state.
Peripheral Vascular System: unable to assess as patient is in a catatonic state.
Hematological system: unable to assess as patient is in a catatonic state.
Endocrine system: unable to assess as patient is in a catatonic state.

Physical Exam:
Vital Signs:
BP: 120/81 (Right arm – sitting)
Pulse: 90
Temp: 99.4 (oral)
RR: 18
O2: 100% on RA
Height: 5’0”; Weight: 42.3kg; BMI: 20.5

General: Patient is casually groomed, catatonic, sitting in the same position.
Skin: warm and dry, no lesions noted.
HEENT:
Head: normocephalic, atraumatic
Ears: hearing, TMs, external ears and ear canal normal AU
Eyes: PERRLA, Conjunctiva, EOMs and lids are normal, no foreign bodies found
Neck: trachea midline, normal ROM, phonation normal, neck supple, no adenopathy
Cardiovascular: normal RR, normal S1, S2, no S3, S4, no gallops or murmurs, carotid pulses 2+ bilaterally without a bruit.
Pulmonary: normal breath sounds, no increased effort
Abdominal: soft, BS present all 4 quadrants
Musculoskeletal: normal ROM, decreased strength
Neurological: A/Ox3, strength and reflexes intact

Mental Status Exam:
General

1. Appearance: JK is below average height, well-nourished male. His hygiene is clean, and he is casually-groomed.
2. Behavior and psychomotor activity: JK is catatonic and mute, unable to answer questions throughout the interview. His mood appears constricted and he exhibits waxy flexibility.  
3. Attitude toward examiner: JK is catatonic and mute, unable to answer questions throughout the interview. 

Sensorium and cognition

1. Alertness and consciousness:  JK is catatonic and mute, unable to answer questions throughout the interview. JK blinked throughout the interview and showed adequate respirations.
2. Orientation: JK is catatonic and mute, unable to answer questions throughout the interview. 
3. Concentration and attention: JK is catatonic and mute, unable to answer questions throughout the interview. Unable to assess. 
4. Capacity to read and write: JK is catatonic and mute, unable to answer questions throughout the interview. Unable to assess.
5. Abstract thinking: JK is catatonic and mute, unable to answer questions throughout the interview. Unable to assess.
6. Memory: JK is catatonic and mute, unable to answer questions throughout the interview. Unable to assess.
7. Fund of information and knowledge: JK is catatonic and mute, unable to answer questions throughout the interview. Unable to assess.

Mood and Affect

1. Mood: JK is catatonic and mute, unable to answer questions throughout the interview. His mood appears constricted.
2. Affect: JK is catatonic and mute, unable to answer questions throughout the interview. His affect is constricted.
3. Appropriateness: JK is catatonic and mute, unable to answer questions throughout the interview, which remained unchanged. 

Motor

1. Speech: JK’s speech is guarded due to catatonia.
2. Eye contact: JK is catatonic but blinked throughout the interview.  Unable to make eye contact.
3. Body movements: JK is catatonic and mute, unable to answer questions throughout the interview. Patient exhibited waxy flexibility on examination.

Reasoning and Control

1. Impulse control: JK’s impulse control is impaired due to catatonia.
2. Judgement: JK’s judgement is impaired due to catatonia.
3. Insight: JK is catatonic and mute, unable to answer questions throughout the interview. Unable to assess.

Differential Diagnosis:

• Catatonic Schizophrenia
  • Per history obtained from patient’s sister, patient has been non-compliant with his medication and has been increasingly ‘sedated.’  Patient previously seen in this ED for catatonia and discharged home after Ativan broke the catatonic state. Given known history of catatonia and diagnosis of schizophrenia, catatonic schizophrenia exacerbation most likely.  
• Nonconvulsive Status Epilepticus
  • Unlikely given patient’s diagnosis and prior history of catatonia, which was broken by Lorazepam.  To be considered due to immobility, mutism, altered mental status and generally bizarre behavior. Patient has no history of seizures or known disorder.
• Encephalopathy
  • Unlikely given the patient’s diagnosis and prior history of catatonia.  Something to consider based on presentation and altered mental status but less likely given history.  Subsequent lab values were normal, no signs of acute medical condition / illness.

Treatment Plan:

1. Admit to N3 as patient is acutely psychotic with a catatonic presentation not breaking in the Extended Observation Unit.
   1. Observation q15 minutes for safety
   2. Continue with Lorazepam 1mg
   3. Continue with Haloperidol 5mg
   4. Continue with Aripiprazole 30mg
   5. Consider Lovenox Injection (40mg) if patient’s catatonia doesn’t break
   6. Arrange a nutrition consult
   7. Follow labs drawn in EOU
   8. Once catatonia breaks, counsel patient on medication adherence and encourage individual & group psychotherapy.