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Identifying Data : B.K.

Age: 21
Sex: Male
DOB: 16th July, 1992
CC: non complaint with Psych medications and aggressive toward family as per
EMS note
HPI:
Mr B.K is a 21 y/o mixed origin man ( African-American and Puerto Rican)man,
single, unemployed, domiciled with grandmother, with previous psychiatric contact
two months ago and no prior history of hospitalizations and history of cannabis use
disorder, severe who BIBEMS in handcuffs, activated by grandmother because the
patient had been yelling uncontrollably at her after having a fight with his girlfriend.
He was seen initially at the medical ER then transferred
The personnel in CPEP had been unable to obtain a complete history from the
patient as he was described as uncooperative and not engaging with any
assessment at all. In CPEP the resident had spoken to his grandmother, Ms.B where
the grandmother had said that the patient had anger management issues and bad
temperament and was in a volatile relationship with a girl and the girlfriend was the
one that had reported that the patient had been "acting strange sometimes
different". The grandmother stated that he has had anger issues and his
temperament and fits of anger have become much worse lately.
As per the grandmother about 2 months ago she had noticed the patient sometimes
talking to himself and he described hearing voices to her. She stated that he
"keeps to himself". He has been increasingly extremely aggressive at home yelling
and shouting for no reason at all and he has stated that he "needs help". He had
become uncontrollably aggressive after having a fight with his girlfriend which
prompted the grandmother to activate EMS.
As per the grandmother she had noticed him smoking marijuana all day and had
enrolled him at Fortune Society two months ago. The CPEP note described him as
oddly spaced out and unable to engage in further conversation and he was seen
actively talking to himself. He was medicated in CPEP with Haldol and Ativan 5 mg
IM and 2 mg IM and sent to the inpatient unit for further stabilization
Past Psychiatric History :
The patients first contact with a Psychiatrist was 2 months ago on June 25 th 2013 at
Fortune Society ( after care for the incarcerated)with Dr.Conti where he was
prescribed Zyprexa 10 mg hs. He has had two visits with Dr.Conti and carries a

diagnosis of Substance Induced psychotic Disorder and PTSD. He has had two visits
in total and has been asked to follow up at St.Lukes Hospital which he has not.
His grandmother claims that he has taken 2-3 doses of his medications. He is not
complaint. There is no recorded history of suicide attempts
Psychkes shows his only contact with Psychiatry was with Fortune Society. There are
no ER visits or inpatient visits otherwise
Medications:
Olanzapine 10 mg hs
Substance Use History:
Cannabis:-First use at the age of 15.Has shared blunts from age of 15-16. He re
started at the age of 20. He rolls multiple joints and shares them with his friends.
His use has been daily since January to August 2013. THC relaxes the patient.
Synthetic marijuana:- First use in January 2013. Increasing use in July 2013.
Ectasy:-First use at the age of 15. He bought pills when he had the money on
weekends and mixed pills into marijunana
Bath salts:-synthetic cathionines(effects similar to amphetamines and cocaine).
First use at 20. His use is occasional weekend use. Increased use during the month
of July 2013.
Molly salts :-made of cocaine, crack,ecstasy and methamphetamine. First use in
January 2013. He uses bath and molly salts when he has adequate money.
His drug of choice is marijuana
Medical/Surgical Hx:
None
Social Hx:
The patient was born to a Puerto Rican mother and an African American father. His
parents separated before the patient was born. His father raised him with his
stepmother and he has a biological older sister and a younger brother. His father
and grandmother live in New York and his sister and biological mother live in North
Carolina. As per the patients grandmother, the patient suffered early neglect as his
biological parents had separated and he had not received attention from his
stepmother. More attention had been given to his younger half-brother.
He is described by both his father and his grandmother as having an angry outlook
and temperament and has always been a troubled child getting into trouble at

school and having temper tantrums at home. His relationship with his father has
been described as rocky as the patient harbours a lot of anger toward him. His
relationship with his mother is fair
At the age of 15, the patient is said to have started using drugs and had fallen in
with a bad crowd. He was using drugs for one year and then was caught selling
crack and sent to Rikers Island for four years from the age of 16 to the age of 20.
The patient was brought up on Muslim faith however his family does not describe
themselves as very religious and the patient was not very religious growing up.
While he was in prison , the patient showed a greater inclination toward religion and
faith. He also got a GED in prison and as per his grandmother he became an avid
reader requesting for books.
The patient was released from prison in January 2013 and initially went to live with
his father and later moved to his grandmothers house secondary to differences
with his stepmother and his younger half-brother. His father describes him as
distrustful and paranoid about many things:- eg:-he believes the patient may refuse
food as he believes that poison may be mixed in his food. He had refused blood
work and
Family History:The patients biological mother and grandmother carry a diagnosis of Bipolar
Disorder. His mother has a history of substance use disorder and is said to have
used crack during her pregnancy with the patient.
A paternal cousin carried a diagnosis of Psychotic Disorder and Substance Use
Legal Hx:
The patient was arrested at the age of 16 for selling drugs. He was incarcerated for
four years at Rikers island.
Trauma/Abuse History:As per the patients grandmother and collateral information received from Fortune
Society the patient was sexually assaulted while in prison and had spent time in
solitary a number of times.
Hospital Course:
When he arrived on the inpatient floor, he was banging on the door and was
extremely loud stated that he wanted to get discharged immediately. He continued
to keep asking for the Quran and was extremely angry when he could not have one
immediately. He was medicated with Haldol 5 mg IM and 2 mg IM. As per the initial
inpatient assessment note, he kept coming up to the writer of the note asking" why

they need all those medications man" "why do they need injections"" you people
are cruel, cruel" and then he stated that he will never take medications nor will be
eat.
His initial four days on the inpatient unit consisted of the patients paranoid
behaviour where he refused to interact with staff and other personnel where he
stated that "I want a Quran" "don't lie to me" ,get me an imam, I want to talk to
an imam. He was internally preoccupied and staring
into space and was talking to himself. He refused to speak to the team stating that
"I don't talk, I'll read the Quran and go to sleep". He was paranoid about staff Stop
playing games with me, youre the ones that are crazy. He was medicated a total
of 3 IM injections on the floor with Haldol 5 mg IM and Ativan 2 mg IM.
The fifth day the patient became less paranoid and started opening up to the
treatment team. He was religiously preoccupied and kept requesting to speak to an
imam and initially had refused to wash himself. The first two times an imam had
been available to see him however the patient had refused to see the imam. He
later began speaking to the imam.
The patient gradually became less paranoid and began sharing his symptoms with
his treatment team. As per the patient during the Ramadan (July-August) he violated
his religion by eating the wrong food and had engaged in sexual intercourse with
both his girlfriend and had engaged in oral sex with a male. The guilt of these
encounters were weighing down on the patient. He admitted to have gone through
traumatic experiences in prison some of which he describes as dark memories he
states that he had made mistakes as a teenager and that he is glad that he went to
prison to pay for them. He is religiously preoccupied and constantly requests to do
the Shahadat and the j ahumm (afternoon Friday prayer).
He has admitted to auditory hallucinations that have begun two months ago. The
voices are intermittent as per him and he hears them when he is praying to Allah,
he believes it is punishment for his sins. This causes him a lot of anxiety.
He has continued to refuse oral medications as he feels that they are not natural
and he believes in natural healing. He is currently being processed to be taken to
court for medication over objection
Current MSE:
Appearance: The patient wears appropriate hospital attire with fair basic hygienic
needs.
Speech: Normal tone, rate, and rhythm
Behaviour: Cooperative
Mood: good

Affect: flat, smiles inappropriately and blunted


Thought Process: illogical, religiously preoccupied
Thought Content: denies homicidal or suicidal ideations.
Perception: denies hallucinations currently, has been seen to be internally
preoccupied and laughing and talking to himself
Cognition: AAOx3 to person, place and time. He demonstrates intact calculation.
Insight: None. Patient does not acknowledge his illness
Judgment: Poor. Patient has stated that he will pray to get rid of his sins
Impulse Control: Poor but has shown fair impulse control over the past three days

Labs:
His urine toxicology was positive for THC
Work up for first episode psychosis:- done
MRI is pending.

SUMMARY:Mr B.K is a 21 y/o mixed origin man ( African-American and Puerto Rican)man,
single, unemployed, domiciled with grandmother, with previous psychiatric contact
two months ago and no prior history of hospitalizations and history of cannabis use
disorder, severe who BIBEMS in handcuffs, activated by grandmother because the
patient had been yelling uncontrollably at her after having a fight with his girlfriend.
When initially brought to CPEP he was internally preoccupied and spaced out and
oddly related eg:- not looking at the writers when they are talking to him. His first
contact with psychiatry was two months ago when his grandmother had noticed
odd behaviour eg:- talking to himself and had become increasingly more
aggressive and belligerent. He was prescribed Zyprexa 10 mg hs which he has
taken 2-3 doses of. Since January 2013 after the patient was released from prison
post being incarcerated for four years on drug charges the patient has been
smoking marijuana upto 4 blunts a day. He also has used K2 (synthetic marijuana),
molly, and bath salts during the last 6 months prior to hospital. His drug of choice is
THC.
Over the last two months the patient has endorsed intermittently hearing voices
which he has stated he hears while praying. He was initially extremely unco-

operative upon first approach and was religiously preoccupied demanding to speak
to an imam and refusing to speak with other staff or peers. He was medicated on a
total of 3 occasions with Haldol and Ativan and his paranoia reduced slightly. A copy
of the Quran was obtained for him and via the help of the multi-disciplinary team an
imam was requested for. The imam has been meeting with the patient almost daily
and the patients paranoia has reduced and his hygiene and grooming have shown
much improvement. He has opened up gradually to the treatment team.
Collateral information obtained from Fortune Society and his family have revealed
detail into the patients psyche. His parents had separated when young, his
relationship with his step mother is not good, he was described as an angry child.
He was arrested for selling drugs at the age of 16 and incarcerated till the age of 20
at Rikers Island. Collateral information indicates that he was sexually assaulted
while incarcerated.
He continues to refuse medications on a daily basis. He believes that his condition is
secondary to sins committed during Ramadan including sexual intercourse with
his girlfriend and another man, using drugs and eating when he was not supposed
to. The patient believes that if he prays and follows his faith he will not face these
troubles. He does not believe in medications, or MRI scans as these not not
natural.
The patient has been able to participate in different groups and has been able to
have one-to-one sessions with the therapist. He is however paranoid, is seen
internally preoccupied at times and demonstrates poor insight and judgment into
his illness and substance use. He remains at imminent danger to himself and
requires inpatient stabilization.

Biological risk factors genetic loading of illness (his mother and maternal
grandmother have a diagnosis of Bipolar Disorder, his mother has a h/o substance
use disorder). His mother used crack during her pregnancy which may have
contributed to his illness and he has a history of substance use disorder
Psychological risk factors include separation of biological parents when young,
neglect when young by stepmother, incarceration at 16, sexual abuse while being
incarcerated.
Social factors include lack of education, lack of employment, interpersonal conflicts
with girlfriend, father and grandmother.
Protective factors include strong faith and a supportive family and girlfriend.
Risk assessment includes a chronic elevated risk to self as he has a mental illness
and history of sexual abuse and extensive substance use. He is at medium risk to

himself as he is paranoid and has several stressors listed above. He is a high risk of
violence ( h/o substance use disorder and h/o incarceration contributes heavily).
Differential Diagnosis includes Substance Induced Psychotic Disorder versus
Unspecified Psychotic Disorder vs Schizophrenia, first episode of psychosis
PLAN:Continue inpatient treatment.
**Biological treatment
Olanzapine 10 mg po bid for psychosis
Klonopin 1 mg po bid, Ativan 2 mg po hs
As the patient refuses oral medications, he is being taken to court for medication
over objection
Will ask for MRI scan when patient is less psychotic
**Psychological treatment
Psychoeducation regarding his illness and substance use
Supportive therapy- he enjoys one on one sessions
Group therapy- likes exercise, mens group.
Addiction counselling
**Social treatment
Daily sessions with imam. Halal tray for food.
Family conference with multidisciplinary team with psychoeducation of family.
Will get CXR( patient was incarcerated- high risk for communicable diseases)
DISPOSITION:Considering MICA program vs grandmothers house
Psychosocial club with similar age group
Young adult clinic
NAMI reference
Discussed with family, and multidisciplinary team.