I hadn’t slept well. It had been a couple of weeks of not sleeping well. On top of a few years of not sleeping well. People describe This kind of not sleeping well as “not sleeping well” in order not to say, “I literally didn’t sleep at all, and that’s definitely pathological, so I’m not going to say that part.” My situation, at least the prior night, debatably still going on at 5 AM, involved the “not sleeping at all” variety of the problem.
It was 5:15 AM. There wasn’t a ferry coming to the dock before me until 6:25 AM. It’s probably worth noting that this was the dead of early spring. It’s like the dead of winter in that it’s just as cold, but it’s early March instead of February, so you can’t say “the dead of winter” and have it be accurate. But it’s still below freezing. I was wearing a coat that wasn’t appropriate. This is also defined according to the situation: no coat is appropriate when you’re just sitting there for long periods and not moving if it’s a coat that would be appropriate for moving around. I was wearing the kind of coat designed to take into account body heat, having been generated over some time thanks to robust strolling. I was not strolling. At best, I was robustly sitting, which was not the intention of the coat designers.
I live next to the East River. Manhattan is flanked by one river on the west side, the Hudson, and one on the east. That river, the East River, separates Brooklyn and Manhattan. On the Brooklyn side, you can live right on the water, as it were. I do. And I did. And there’s a ferry that comes to a dock. It’s a good boat. It’s a reliable boat. It’s not a far walk from my house. And so I was waiting for that boat to get me. The other side of that boat ride was a total of 15 minutes away. NYU Langone Medical Center has an emergency room with an entrance at 33rd St. and First Avenue, one block from the ferry. Instead of taking some more sensible form of transport, something like a cab, that would’ve taken me right there, or a subway, which would’ve moved me on my way, and probably gotten me there at the same time, I decided to allow my ambivalence about the whole situation to dictate my mode of travel, and I selected the mode of travel that wouldn’t come for another hour. In my mind, I had no choice but to wait. As we will see, my mind was acting quite unreliably at that time. I had headphones on. They were playing music that was dark. There was ice on the ground, and I was wearing Converse, which are inappropriate shoes in these conditions. It was quiet, and the early morning pre-dawn light was flickering in the presumably halogen bulbs of the streetlights positioned on the boardwalk. Frankly, I wasn’t in a rush. Because I knew where I was going. And I thought I knew why I was going. I couldn’t stop thinking about why I was going. Something was wrong.
The image of pouring gasoline over oneself and lighting a match is not a pleasant one. It’s not pleasant even when you’re thinking about someone else doing it, who is invariably a monk. Monks are in virtually all the pictures of this activity because the most viewed image of this is on Rage of The Machine’s breakthrough album. Monks are different from regular people. Monks are not you or me on average. You don’t go to work wearing a monk outfit unless you’re a monk. Monks are conceptually far enough from early-40s, tubby, balding, white physicians as to allow for a emotional and cognitive distance. This distance is what allows people, including myself prior to this moment, to look at these pictures of monks burning themselves alive and not immediately have the uncomfortable imagined experience of it being themselves. It makes these pictures bearable.
Have you ever burned your hand? I have. You probably have, too. You might have done it by touching a hot plate, or taking something out of the oven, or something like that. If you’re really unlucky, you had a bad run-in with a firework. But because of these minor burns, you’re aware of how bad an idea burning yourself alive is. Almost everyone is. Don’t touch the hot thing. Don’t leave the stove on. Did you turn off the oven? There are entire psychiatric disorders based on the fear of not turning off the oven and having to check.
But pouring gasoline on oneself and then lighting a match–that’s something most of us don’t do. Even the most suicidal of individuals usually think about things that will get the job done quickly and painlessly. There’s a lot of fantasizing about getting hit by buses that happens among the chronically suicidal. Stepping in front of subway cars is something that goes through one’s head repeatedly for many, many people. Overdoses of pills seem like they’ll be nice for some folks. Large amounts of sleeping pills are frequently recommended by brains obsessing about annihilation. People will buy this or that to die quickly. Guns will end the “being alive” situation quickly. There are so many ways to imagine dying that are presumably pain-free. I promise you-- they’re not. As someone who’s done a lot of consultation in ICUS with people who made suicide attempts that did not lead to death, I can verify that it’s a terrible idea to do any of these things.
The experience of burning alive seems like it would be so horrific that even those who crave death avoid thinking about it. And yet here I was, sitting in the very, very cold morning and thinking, repeatedly, without having much say in the matter, of having my body be engulfed in unbelievably painful flames for as long as it would take to go into cardiac arrest.
I’ve worked in burn trauma ICUs. I have seen the many months of painful recovery, IV pain control, sedation, skin grafting, and the rest. It is a miserable-fuck thing, even if it happened on accident. It’s a miserable-fuck thing if you did it on purpose. It’s an unimaginable thing for anybody but a monk. And apparently, me.
Here I was, sitting in the 20° early spring cum late winter weather, freezing my ass off, listening to Danny Carey drum away on the most recent Tool album, with images I did not find pleasant running through my mind. They seemed wrong. This kind of thing didn’t make much sense to be thinking. I was frustrated about stuff in life but not even depressed. Annoyed, at best. Stymied? However, the internal world I was living in did not inspire the kind of despair that would usually be aligned with fantasizing about ending one’s life. If I had just wanted to experience pain and suffering endlessly, I could have just submitted more prior authorizations to United Healthcare for perfectly reasonable treatments and have them denied. Then, I could have easily simulated the experience of mortifying pain without all the hustle and bustle of having tortured myself like I was a protester in the Vietnam War. God, it’s cold out. I moved my toes. First up, then down. Then up, up and down. Then, up and down. And I pressed them down hard inside my Converse. During all this ice and fire, the right Converse sneaker was also seriously failing: the bottom was detaching. These were not structurally robust sneakers at that point in time. But they’re all I had. I took out my phone. Five minutes had passed. Sigh. That’s not enough minutes. It was also more minutes than I would have liked.
I have bipolar disorder. I have been depressed and suicidal before. This mental state was not a completely novel experience for me. But it was strange, even compared to prior psychiatric episodes in my life. I was aware that this was different. I was also aware of what was waiting for me on the other side of the East River in the emergency room of NYU Langone Medical Center. I knew that I was going to walk in. I was going to shuffle a little bit because my feet would be as cold as they were then. I was going to have to go to the registration desk. I was going to hand them my insurance card. They would ask me why I was there. I would tell them, “I am thinking about killing myself.” They would ask me to take a seat. There would be a period of waiting. And then some more waiting. Eventually, someone would come and take my blood pressure.
Fast forward. Let’s assume that’s happening right now in the story.
I sat down in the chair, slipped my arm out of the insufficient winter jacket, and pulled back my sleeve as they wrapped the blood pressure cuff around my arm. “Hmmm…hmmm. Hmmm. Hmmm hmmm hmmm, hmmm, hmmm, hmmm, hmmm, hmmm, mama.” was the sound of the blood pressure cuff inflating as the air compressor did its level best to figure the fuck out what was happening with my blood pressure. They stuck a lame plastic condom-esque thingamabob around the thermometer that they placed, with a lack of gingerness, under my tongue. For whatever reason, this was the point in time when they decided to ask me again why I was there.
“Bad blood by blah blah blah blah blah to draw myself that that that should about that.”
“I’m sorry, I didn’t hear that come out. What brought you in today?”
I take the thermometer out of my mouth.
“I was having suicidal thoughts, but you asked me when I had a thermometer in my mouth. It’s hard to both have it not fall out and say those things. That’s why you can’t understand me. I’m sorry. I’ll put the thermometer back in now.”
I placed the thermometer back in my mouth.
“Shhhhhhhbhbhbbbbbbhhhhhhhh. Beep!” exclaimed the blood-pressure-cuff-thermometer-combo-unit.
The nurse leaned in, knowingly. Her eyes did a quick survey of the screen, which was not pointing towards me.
“What is it?” I asked.
“It’s a little high. 135/90.”
“Yeah. I don’t think I took my blood pressure medicine last night.”
I take medicine for my blood pressure. It’s a medicine that I originally started taking for the condition that I have. It’s psychiatrically impactful but cardiogenic: benign supraventricular tachycardia. What this means is that my heart randomly beats too fast. Like, way too fast, like, way more than panic fast. I have a rogue area of my left atrium that generates extra beats faster than the sinoatrial node. The sinoatrial node is supposed to create my heart’s electrical rhythm, but I’ve got an alternate node–a literally different drummer–that my heart beats to.
Twenty minutes later, a nurse whom I recognized from five years ago when I used to work in this emergency room walked me back to the psychiatric area of this general medical emergency room. The psychiatric area has two rooms. One of the rooms I was last present in when my patient, Mona, spent her last night alive in this room.
I went through the seemingly locked door of the psychiatric mini area. I had to give them all my things. Giving up all your things, which includes all your clothing, is an unbelievably annoying but time-tested routine in psychiatric evaluation settings. It is as if there’s something magical about wearing a hospital gown that doesn’t allow you to do anything dangerous. It's as if that magical power that the ER must keep you safe is having you wear something deeply embarrassing and denying access to any of your stuff.
It’s been hours already, since I slept. This was an unsettling room to be in. I was unsettled. The junior ER resident walked in. I told her my story. That week, I had gotten a lot done. By “a lot done,” I had helped arrange for the acquisition of a friend's company, and I had submitted a publication to a major journal. I had to make a report with the Securities and Exchange Commission about another matter. I realize, in retrospect, this sounds totally crazy. There was more, I don’t want to bore you, I don’t think I bored the junior resident. The Psychiatry Attending joined her 20 minutes later. As is the tradition in emergency rooms, I told my story all over again. A few more details…
“That’s really helpful, Owen.”
The most important question, of course, was:
“Who do you see as a Psychiatrist?”
Because I sounded totally crazy, they also needed the information so they could contact my wife. It occurred to me, after these two left the room, that the attending psychiatrist thought I was manic. The amount I had gotten done that week was not typical for most people. I’ll acknowledge that. However, I had a sincere plan at this point in time to kill myself, at least according to my brain. And something wasn’t right about it. Why was I thinking about pouring gasoline on my head? I was tired. I hadn’t slept, but I wasn’t feeling well rested. The criteria for the manic phase of bipolar disorder generally include a decreased drive for sleep. It’s not just “not sleeping.” I fretted about the diagnostic criteria that I did or did not meet. Something was wrong with my brain. Something had been wrong the whole night. It may be, likely, absolutely, have been wrong for a little while now. Why was it so wrong? The attending came back, with the resident in tow, three paces behind, as is typical in the culture of medicine.
“We talked to your psychiatrist. That’s quite a week you’ve had, Dr. Muir.”
Oh, so it’s Doctor now?
Some phone calls went back and forth. A plan was formed for me to see my TMS doctor, who could stimulate my brain and solve this problem. The note reveals a patient who is, you know, a grandiose asshole.[1]
They didn’t have transcranial magnetic stimulation in the hospital. That had been the only effective treatment for me. So, they couldn’t admit me to a hospital where they couldn’t treat me. I wasn’t crazy, or at least not the way that they were worried about. I was worried.
The resident returned to the room with discharge paperwork. “I have one more question. You came here for a reason. Are you going to be okay?”
“Good question,” I replied.
I left the emergency room and traveled uptown to get a session of brain stimulation. I got home later that night. I felt ashamed. I felt a little bit better, albeit still on edge.
“When did you start to taper the restless leg medicine?” Carlene asked.
Oh. Shit. I had gone down by 50%. That decrease in dosage of a non-psychiatric medicine was about three weeks ago, but all the prior decreases in dose were by less of a percentage. 4 mg to 3 mg is 25%. 3 mg to 2 mg 33%. This month’s decrease. 0.5 mg to 0.25 mg. That 50% could’ve killed me. The ER missed the diagnosis—acute withdrawal from a dopamine agonist can be precipitated by a taper even just a little too rapid. We refer to this as dopamine agonist withdrawal syndrome. According to the Journal of the American Medical Association:
Symptoms of DAWS resembled those of other drug withdrawal syndromes and included anxiety, panic attacks, agoraphobia, depression, dysphoria, diaphoresis, fatigue, pain, orthostatic hypotension, and drug cravings.
Conclusions Dopamine agonists have a stereotyped withdrawal syndrome that can lead to profound disability in a subset of patients. Physicians should monitor patients closely when tapering these medications.[2]
Suicide attempts have been described in the literature.[3]
I took 0.5mg of pramipexole that night. I awoke the next morning, with the dawn. I felt right as rain. I include the ER note in the footnotes. They thought the answer was to rule out narcassistic personality disorder.
[1] EMERGENCY PSYCHIATRY CONSULT INITIAL NOTE
Triage Date/Time: 12/9/2021, 7:10 AM
Attending Physician: Naseem Moridzadeh, MD
Primary Care Provider: Noah P Canlas
Source of Information: patient
Reliability: fair
Patient Language: English
Interpreter: Not needed
Accompanied by: no one
Consult Type: In person
Reason for Consult:
Suicidal Ideations
Chief Complaint:
"I have depression, worse from the seasonal change."
History of Present Illness:
ID:
Mr. Owen Muir is a married, domiciled, employed 42 y.o. Caucasian male with a long psychiatric history of Bipolar disorder, one prior psychiatric hospitalization, no prior suicide attempts, with a past medical history of psoriatic arthritis, pelvic floor dysfunction, who presents to the emergency department with worsening symptoms of depression.
Owen Muir presents to the emergency department this morning as a walk in for worsening symptoms of a long history of bipolar 1 disorder, current episode depressed. He endorses "this happens every season." He endorses chronic intrusive thoughts of suicide, but denies any active intent or plans to end his life. He provocatively states, "I can douse myself in gasoline, I can jump off a bridge, I can jump off my building, but I have not done any preparatory actions for anything. I'm indifferent to the idea." He identifies his wife and twin children as protective factors, stating "I've seen what happens to children with parents who completed suicide, and I would not do that to my kids." Owen Muir is a practicing psychiatrist with a clinic in Brooklyn, called Brooklyn Minds. He describes at length his knowledge about psychiatry as well as his involvement in psychiatric research, specifically regarding TMS studies, "I'm responsible for 30% of the TMS research on Depression." Despite worsening feelings of depression, and chronic thoughts of suicide, Owen Muir notes that he has had success with treatments of ketamine and TMS in the past, and that he can go to his previous doctor who he received TMS from, Dr. Robert McMullen, later today. When asked why he came into the Emergency Department today, rather than going straight to receive TMS treatment, the patient notes that he thought he may have benefited from ECT treatment. At this time, he denied wishes to be admitted to the inpatient unit.
Reviewed vital signs, physical exam, and review of systems in the medical note.
Collateral Information:
Dr. Robert McMullen, MD called and was aware of the patient's past psychiatric history. He had successfully treated the patient with TMS in the past. He also corroborated the patient's history of severe depression with chronic thoughts of suicide that occurred seasonally. He also corroborates the patient's hypomanic, grandiose, and likely character pathological traits.
Dr. McMullen also corroborates that Owen Muir can be seen later today to receive TMS treatment.
Dr. Michael Dulchin, MD is the patient's current psychiatrist for about 20 years. He was called and corroborates Owen Muir's story and is agreeable with the plan for him to receive TMS today, with follow up with Dr. Dulchin soon.
Carlene MacMillin (patient's wife) was called but did not answer.
Admission Screens:
Results of C-SSRS (suicide) and AUDIT-C (alcohol use disorder) screens reviewed.
Discharged from Inpatient Psychiatry within Past 30 Days:No
Past Psychiatric History:
Bipolar 1 disorder
1 prior psychiatric hospitalization many years ago for a depressive episode.
Reports currently seeing Dr. Mike Dulchin.
As per patient, Owen Muir has been on "every mood stabilizer, and second generation antipsychotic, but I can't take it because of the dopamine blocking properties worsens my restless leg syndrome."
Substance Abuse History:
Denies current drug use.
Past Medical History:
Diagnosis
Date
•
Bipolar 1 disorder
•
Fatty liver
from meds, high LFTS
•
GERD (gastroesophageal reflux disease)
severe
•
HLD (hyperlipidemia)
•
Infectious mononucleosis
•
Migraines
•
Narcolepsy
•
Pelvic floor dysfunction
•
Psoriasis, guttate
•
Psoriatic arthritis
•
RSI (repetitive strain injury)
~2005
both hands/wrists - EMG negative, resolved w/ Graston technique from chiropractor
•
Streptococcus A carrier or suspected carrier
•
Streptococcus C
•
Tenosynovitis
Past Surgical History:
Procedure
Laterality
Date
•
APPENDECTOMY
•
COLONOSCOPY W/ POLYPECTOMY
N/A
11/20/2020
COLONOSCOPY WITH POLYPECTOMY AND ENDOSCOPIC BIOPSY performed by Karl Thadeus Bednarek, MD at TH ACC ENDOSCOPY AND SURGICAL CENTER
•
TONSILLECTOMY AND ADENOIDECTOMY
05/19/2016
Outpatient Meds: (Not in a hospital admission)
No current facility-administered medications for this encounter.
Current Outpatient Medications
Medication
Sig
Dispense
Refill
•
ixekizumab (TALTZ AUTOINJECTOR) AtIn injection
Inject 1 mL into the skin every 28 days. To be used after loading dose.
3 mL
1
•
fluconazole (DIFLUCAN) 200 mg tablet
Take 1 tablet by mouth once a week.
12 tablet
1
•
DEPLIN, ALGAL OIL, 15-90.314 mg Cap
TAKE 1 CAPSULE BY MOUTH EVERY DAY
90 capsule
1
•
metoprolol succinate (TOPROL XL) 50 mg XL tablet
Take 1 tablet by mouth daily.
90 tablet
2
•
predniSONE (DELTASONE) 10 mg tablet
Take 1 tablet by mouth daily.
30 tablet
5
•
CONTRAVE 8-90 mg TbSR tablet
(Patient not taking: Reported on 3/1/2021)
•
metFORMIN (GLUCOPHAGE) 500 mg tablet
(Patient not taking: Reported on 3/1/2021)
•
pramipexole (MIRAPEX) 0.25 mg tablet
•
buPROPion XL (WELLBUTRIN XL) 150 mg 24 hr tablet
150 mg.
•
diazePAM (VALIUM) 2 mg tablet
2 mg.
•
raNITIdine (ZANTAC) 300 mg tablet
300 mg. (Patient not taking: Reported on 3/1/2021)
•
rosuvastatin (CRESTOR) 10 mg tablet
10 tablets.
•
PANTOPRAZOLE SODIUM (PANTOPRAZOLE ORAL)
Take 40 mg by mouth 2 (two) times daily.
•
Syringe with Needle, Disp, (BD ALLERGY SYRINGE) 1 mL 28 gauge x 1/2" Syrg
by Misc.(Non-Drug; Combo Route) route once a week. (Patient not taking: Reported on 11/4/2020)
30 Syringe
1
•
diclofenac sodium 2 % SoPk
Apply 40 mg topically 2 (two) times daily. (Patient not taking: Reported on 3/1/2021)
•
traZODone (DESYREL) 50 mg tablet
Take 50 mg by mouth nightly as needed for Sleep. (Patient not taking: Reported on 3/1/2021)
•
alfuzosin (UROXATRAL) 10 mg SR tablet
Take 10 mg by mouth daily. Take with food. (Patient not taking: Reported on 3/1/2021)
•
lisdexamfetamine (VYVANSE) 50 mg capsule
Take 60 mg by mouth every morning. (Patient not taking: Reported on 3/1/2021)
•
ranitidine (ZANTAC) 300 mg capsule
Take 300 mg by mouth 2 (two) times daily.
•
BUPROPION HCL (WELLBUTRIN ORAL)
Take 150 mg by mouth.
•
DIAZEPAM ORAL
Take 2 mg by mouth 3 (three) times daily.
•
OLANZapine (ZYPREXA) 2.5 mg tablet
Take 2.5 mg by mouth nightly. (Patient not taking: Reported on 3/1/2021)
•
ROSUVASTATIN CALCIUM (CRESTOR ORAL)
Take 10 mg by mouth.
Allergies
Allergen
Reactions
•
Levaquin [Levofloxacin]
Other (See Comments)
unknown
•
Bactrim [Sulfamethoxazole-Trimethoprim]
Urticaria (Hives)
•
Humira [Adalimumab]
Rash
•
Zofran Odt [Ondansetron]
Rash
Temp: [36.7 °C (98.1 °F)]
Heart Rate: [73]
Resp: [19]
BP: (142)/(94)
SpO2: [99 %]
Vital Signs:
12/09/21 0714
BP:
142/94
Pulse:
73
Resp:
19
Temp:
36.7 °C (98.1 °F)
Diagnostic Studies and lab results reviewed. Notable findings:
Results for orders placed or performed during the hospital encounter of 12/09/21 (from the past 24 hour(s))
CBC WITH DIFFERENTIAL
Collection Time: 12/09/21 9:19 AM
Result
Value
WHITE BLOOD CELL COUNT
8.3
NUCLEATED RED BLOOD CELLS %
0
NUCLEATED RBC,ABSOLUTE
0.0
RED BLOOD CELL COUNT
7.04 (H)
HEMOGLOBIN
13.6 (L)
HEMATOCRIT
44.3
MEAN CORPUSCULAR VOLUME
62.9 (L)
MEAN CORPUSCULAR HEMOGLOBIN
19.3 (L)
MEAN CORPUSCULAR HEMOGLOBIN CONC
30.7 (L)
RDW-CV
18.3 (H)
RDW-SD
35.0 (L)
PLATELET COUNT
236
MEAN PLATELET VOLUME
10.5
IMMATURE PLATELET FRACTION, %
6.6
IMMATURE PLATELET FRACTION, ABSOLUTE
15.6
DIFFERENTIAL TYPE
AUTOMATED
NEUTROPHILS %
52
LYMPHOCYTES %
35
MONOCYTES %
11
EOSINOPHILS %
1
BASOPHILS %
1
GRANULOCYTES, IMMATURE %
0
NEUTROPHILS ABSOLUTE
4.4
LYMPHOCYTES ABSOLUTE
2.9
MONOCYTES ABSOLUTE
0.9 (H)
EOSINOPHILS, ABSOLUTE
0.1
BASOPHILS ABSOLUTE
0.0
GRANULOCYTES IMMATURE , ABSOLUTE
0.0
BASIC METABOLIC PANEL
Collection Time: 12/09/21 9:19 AM
Result
Value
SODIUM
140
POTASSIUM
4.1
CHLORIDE
106
CARBON DIOXIDE
24
BLOOD UREA NITROGEN
9
CREATININE
0.88
GLUCOSE
108 (H)
CALCIUM
9.6
EGFR (CKD-EPI) LOWER LIMIT
105.9
EGFR (CKD-EPI) UPPER LIMIT
122.8
ANION GAP
10
HEPATIC PANEL
Collection Time: 12/09/21 9:19 AM
Result
Value
ALBUMIN
4.2
PROTEIN, TOTAL
7.4
BILIRUBIN DIRECT
0.2
BILIRUBIN TOTAL
0.7
AST
61 (H)
ALT
121 (H)
ALKALINE PHOSPHATASE
78
ACETAMINOPHEN LEVEL
Collection Time: 12/09/21 9:19 AM
Result
Value
ACETAMINOPHEN LEVEL
<3
SALICYLATE LEVEL
Collection Time: 12/09/21 9:19 AM
Result
Value
SALICYLATE LEVEL
<5.0
ALCOHOL LEVEL
Collection Time: 12/09/21 9:19 AM
Result
Value
ETHYL ALCOHOL
<10
THYROID STIMULATING HORMONE
Collection Time: 12/09/21 9:19 AM
Result
Value
TSH HIGH SENSITIVITY
2.25
Social History:
Social History
Socioeconomic History
•
Marital status:
Married
Spouse name:
Not on file
•
Number of children:
Not on file
•
Years of education:
Not on file
•
Highest education level:
Not on file
Occupational History
•
Occupation:
psychiatrist
Tobacco Use
•
Smoking status:
Never Smoker
•
Smokeless tobacco:
Never Used
Vaping Use
•
Vaping Use:
Never used
Substance and Sexual Activity
•
Alcohol use:
No
•
Drug use:
No
•
Sexual activity:
Not Currently
Other Topics
Concern
•
Not on file
Social History Narrative
•
Not on file
Social Determinants of Health
Financial Resource Strain:
•
Difficulty of Paying Living Expenses: Not on file
Food Insecurity:
•
Worried About Running Out of Food in the Last Year: Not on file
•
Ran Out of Food in the Last Year: Not on file
Transportation Needs:
•
Lack of Transportation (Medical): Not on file
•
Lack of Transportation (Non-Medical): Not on file
Physical Activity:
•
Days of Exercise per Week: Not on file
•
Minutes of Exercise per Session: Not on file
Stress:
•
Feeling of Stress : Not on file
Social Connections:
•
Frequency of Communication with Friends and Family: Not on file
•
Frequency of Social Gatherings with Friends and Family: Not on file
•
Attends Religious Services: Not on file
•
Active Member of Clubs or Organizations: Not on file
•
Attends Club or Organization Meetings: Not on file
•
Marital Status: Not on file
Intimate Partner Violence:
•
Fear of Current or Ex-Partner: Not on file
•
Emotionally Abused: Not on file
•
Physically Abused: Not on file
•
Sexually Abused: Not on file
Housing Stability:
•
Unable to Pay for Housing in the Last Year: Not on file
•
Number of Places Lived in the Last Year: Not on file
•
Unstable Housing in the Last Year: Not on file
No current facility-administered medications on file prior to encounter.
Current Outpatient Medications on File Prior to Encounter
Medication
Sig
Dispense
Refill
•
ixekizumab (TALTZ AUTOINJECTOR) AtIn injection
Inject 1 mL into the skin every 28 days. To be used after loading dose.
3 mL
1
•
fluconazole (DIFLUCAN) 200 mg tablet
Take 1 tablet by mouth once a week.
12 tablet
1
•
DEPLIN, ALGAL OIL, 15-90.314 mg Cap
TAKE 1 CAPSULE BY MOUTH EVERY DAY
90 capsule
1
•
metoprolol succinate (TOPROL XL) 50 mg XL tablet
Take 1 tablet by mouth daily.
90 tablet
2
•
predniSONE (DELTASONE) 10 mg tablet
Take 1 tablet by mouth daily.
30 tablet
5
•
CONTRAVE 8-90 mg TbSR tablet
(Patient not taking: Reported on 3/1/2021)
•
metFORMIN (GLUCOPHAGE) 500 mg tablet
(Patient not taking: Reported on 3/1/2021)
•
pramipexole (MIRAPEX) 0.25 mg tablet
•
buPROPion XL (WELLBUTRIN XL) 150 mg 24 hr tablet
150 mg.
•
diazePAM (VALIUM) 2 mg tablet
2 mg.
•
raNITIdine (ZANTAC) 300 mg tablet
300 mg. (Patient not taking: Reported on 3/1/2021)
•
rosuvastatin (CRESTOR) 10 mg tablet
10 tablets.
•
PANTOPRAZOLE SODIUM (PANTOPRAZOLE ORAL)
Take 40 mg by mouth 2 (two) times daily.
•
Syringe with Needle, Disp, (BD ALLERGY SYRINGE) 1 mL 28 gauge x 1/2" Syrg
by Misc.(Non-Drug; Combo Route) route once a week. (Patient not taking: Reported on 11/4/2020)
30 Syringe
1
•
diclofenac sodium 2 % SoPk
Apply 40 mg topically 2 (two) times daily. (Patient not taking: Reported on 3/1/2021)
•
traZODone (DESYREL) 50 mg tablet
Take 50 mg by mouth nightly as needed for Sleep. (Patient not taking: Reported on 3/1/2021)
•
alfuzosin (UROXATRAL) 10 mg SR tablet
Take 10 mg by mouth daily. Take with food. (Patient not taking: Reported on 3/1/2021)
•
lisdexamfetamine (VYVANSE) 50 mg capsule
Take 60 mg by mouth every morning. (Patient not taking: Reported on 3/1/2021)
•
ranitidine (ZANTAC) 300 mg capsule
Take 300 mg by mouth 2 (two) times daily.
•
BUPROPION HCL (WELLBUTRIN ORAL)
Take 150 mg by mouth.
•
DIAZEPAM ORAL
Take 2 mg by mouth 3 (three) times daily.
•
OLANZapine (ZYPREXA) 2.5 mg tablet
Take 2.5 mg by mouth nightly. (Patient not taking: Reported on 3/1/2021)
•
ROSUVASTATIN CALCIUM (CRESTOR ORAL)
Take 10 mg by mouth.
No current facility-administered medications for this encounter.
Current Outpatient Medications
Medication
Sig
Dispense
Refill
•
ixekizumab (TALTZ AUTOINJECTOR) AtIn injection
Inject 1 mL into the skin every 28 days. To be used after loading dose.
3 mL
1
•
fluconazole (DIFLUCAN) 200 mg tablet
Take 1 tablet by mouth once a week.
12 tablet
1
•
DEPLIN, ALGAL OIL, 15-90.314 mg Cap
TAKE 1 CAPSULE BY MOUTH EVERY DAY
90 capsule
1
•
metoprolol succinate (TOPROL XL) 50 mg XL tablet
Take 1 tablet by mouth daily.
90 tablet
2
•
predniSONE (DELTASONE) 10 mg tablet
Take 1 tablet by mouth daily.
30 tablet
5
•
CONTRAVE 8-90 mg TbSR tablet
(Patient not taking: Reported on 3/1/2021)
•
metFORMIN (GLUCOPHAGE) 500 mg tablet
(Patient not taking: Reported on 3/1/2021)
•
pramipexole (MIRAPEX) 0.25 mg tablet
•
buPROPion XL (WELLBUTRIN XL) 150 mg 24 hr tablet
150 mg.
•
diazePAM (VALIUM) 2 mg tablet
2 mg.
•
raNITIdine (ZANTAC) 300 mg tablet
300 mg. (Patient not taking: Reported on 3/1/2021)
•
rosuvastatin (CRESTOR) 10 mg tablet
10 tablets.
•
PANTOPRAZOLE SODIUM (PANTOPRAZOLE ORAL)
Take 40 mg by mouth 2 (two) times daily.
•
Syringe with Needle, Disp, (BD ALLERGY SYRINGE) 1 mL 28 gauge x 1/2" Syrg
by Misc.(Non-Drug; Combo Route) route once a week. (Patient not taking: Reported on 11/4/2020)
30 Syringe
1
•
diclofenac sodium 2 % SoPk
Apply 40 mg topically 2 (two) times daily. (Patient not taking: Reported on 3/1/2021)
•
traZODone (DESYREL) 50 mg tablet
Take 50 mg by mouth nightly as needed for Sleep. (Patient not taking: Reported on 3/1/2021)
•
alfuzosin (UROXATRAL) 10 mg SR tablet
Take 10 mg by mouth daily. Take with food. (Patient not taking: Reported on 3/1/2021)
•
lisdexamfetamine (VYVANSE) 50 mg capsule
Take 60 mg by mouth every morning. (Patient not taking: Reported on 3/1/2021)
•
ranitidine (ZANTAC) 300 mg capsule
Take 300 mg by mouth 2 (two) times daily.
•
BUPROPION HCL (WELLBUTRIN ORAL)
Take 150 mg by mouth.
•
DIAZEPAM ORAL
Take 2 mg by mouth 3 (three) times daily.
•
OLANZapine (ZYPREXA) 2.5 mg tablet
Take 2.5 mg by mouth nightly. (Patient not taking: Reported on 3/1/2021)
•
ROSUVASTATIN CALCIUM (CRESTOR ORAL)
Take 10 mg by mouth.
Review of systems:
Constitutional/Pain: Neg
HEENMT: Neg
Cardio-Vasc: Neg
Resp: Neg
GI: Neg
GU: Neg
Musc/Skel: Neg
Skin/Breast: Neg
Neuro/EPS: Neg
Endo: Neg
Heme/Lymph: Neg
Allergy/Immuno: Neg
Mental Status Exam:
Appearance: Clean/neat
Behavior: confrontational
Psychomotor Activity: within normal limits
Gait: patient was in hospital bed
Speech: pressured and soft
Mood: irritable
Affect: normal affect
Thought Process: goal directed
Thought Content: suicidal
Perception: no perceptual abnormalities
Cognition: grossly intact
Insight/Judgement:normal insight and judgment
Impulse Control: fair
Assessment and Plan:
Bipolar 1 disorder, current episode mixed
Rule out Narcissistic personality disorder
Mr. Owen Muir is a married, domiciled, employed 42 y.o. Caucasian male with a long psychiatric history of Bipolar disorder, one prior psychiatric hospitalization, no prior suicide attempts, with a past medical history of psoriatic arthritis, pelvic floor dysfunction, who presents to the emergency department with worsening symptoms of depression.
Owen Muir appears to have insight into his current situation. He appears irritable on exam and attributes this to poor sleep the night before. Despite denying any hypomanic symptoms, he exhibits grandiose thinking as he was provocative in describing his accomplishments and accolades at length. He was also provocative in explaining his diagnosis, current symptomatology, and his thoughts of suicide. Given the patient's history of chronic thoughts of suicide, his provocative behavior, and his plan to receive outpatient treatment that had been successful in the past, he is unlikely to benefit from an inpatient admission, and would most benefit from treatment in the outpatient with his regular psychiatrist, as well as his TMS psychiatrist.
Case discussed with Psychiatric ED director, Dr. Andrew O'Hagan.
[2] Rabinak CA, Nirenberg MJ. Dopamine Agonist Withdrawal Syndrome in Parkinson Disease. Arch Neurol.2010;67(1):58–63. doi:10.1001/archneurol.2009.294
[3] Espindola M, Rojas NG, Vaisentein G, Da Prat G, Cesarini M, Etcheverry JL, Gatto EM. Suicide attempt in a dopamine agonist withdrawal syndrome in Parkinson's disease. Parkinsonism Relat Disord. 2024 Apr;121:106017. doi: 10.1016/j.parkreldis.2024.106017. Epub 2024 Feb 12. PMID: 38401377.