Site Evaluator: Manual Saint Martin, MD 

For my first visit, I presented an H&P on a 22 year old male presenting in CPEP triage for depressed and suicidal thoughts. Despite being on Lexapro 10mg tablets, the patient reported feelings of sadness, homelessness, unintentional weight loss, decreased sleep, and disinterest in doing anything. Upon psychiatric examination, the patient exhibited fair judgment but with impaired impulsivity.  My differential diagnoses included major depressive disorder, borderline personality disorder, persistent depressive disorder, and medication/substance-induced depressive disorder. Based on the patient’s history and psychiatric evaluation, the patient most likely had Major Depressive Disorder. Given the patient’s suicidal thoughts and history of suicidal attempts, the team decided that the patient warranted overnight observation in CPEP for further observations and stabilization. I chose this case because it was the first patient that I did a mental status on and created a safety plan with. When I presented the case to Dr. Saint Martin, we discussed possible treatment options and appropriate medication dosing as the patient was likely on too low of a Lexapro dose. He agreed with my differential diagnoses. 

For my final site visit, I presented a case of a 19 year old male presenting in CPEP triage for agitation and erratic behavior. NYPD was called after he was found to be hitting the neighbor’s door with a metal hammer looking for his “fiancé”. He was found to have a history of substance-induced psychosis (daily use of marijuana and weekly use of alcohol), delusions, auditory hallucinations, and physical aggressiveness. Upon psychotic examination, the patient presented with poor judgment and poor insight, with illogical thought processes and delusional and paranoid content. My differential diagnosis included substance-induced psychosis, delusion disorder, schizophrenia, antisocial disorder, and bipolar I disorder. He has previously been prescribed Risperidone, but is noncompliant as he believes he is “perfectly fine, I just smoke weed.” Due to his current presentation and his history of substance use and physical aggression, the patient likely is presenting with substance-induced psychotic disorder. As the patient is noncompliant with his medications, he poses a possible danger to others, warranting overnight admission in CPEP for further stabilization and overnight observation. I chose this case because of the impact speaking to the mother in person had on me and the feeling of helplessness, as she couldn’t force her son to follow up in outpatient care because he is an adult and he doesn’t qualify to be admitted inpatient. Dr. Saint Martin really challenged me and made a good point on whether the patient was actually under the influence of a substance during the times he was physically aggressive or delusional about his neighbor, whereas I just assumed he was because he reported daily use of marijuana. I expressed that I didn’t specifically ask the patient those questions, but believe it is notable that his mother said his behavior worsened after he started smoking marijuana and drinking alcohol. When discussing differential diagnoses, I made sure to point out that none of the diagnoses can fully be determined while the patient was still using substances. The one differential that Dr. Saint Martin questioned was whether the patient had antisocial disorder or was just exhibiting antisocial behavior, which I had actually not thought about, but I clarified that because the patient had not shown any symptoms of conduct disorder at the age of 15 it was lower on my differential list.