My psychiatry site evaluation was very educational, and my site evaluator did an excellent job at answering questions we had and providing feedback on our presentations. From my first site evaluation I learned that it’s always important to know and question why a certain treatment plan was decided on. For instance, it’s not enough to just write, “admit for inpatient psychiatric services;” you should include what should be done for the patient once they are admitted. You should know what medications should be given to stabilize the patient, as well as the medications that should be ordered for maintenance therapy. During my final site evaluation, I learned how important it is to write an extensive HPI and differential diagnosis, so that other providers can obtain as much information as possible on the patient. This is especially important in psychiatry when treating patients with mental illness. The following is an HPI from one of the patients I presented on during my site evaluation: 

“A.Z. is a 24 year old single Arab male, unemployed, domiciled with mother, father (Farheed xxx-xxx-xxxx), and brother, with no past medical history and a past psychiatric history of Polysubstance Abuse and Bipolar I Disorder (noncompliant, unkown medications), who was brought in to the Queens Hospital Center Medical Emergency Room by Emergency Medical Services activated by unknown source due to patient demonstrating bizarre and inappropriate sexual behaviors in public. As per EMS report, the patient was masturbating in public. 

Upon initial psychiatric evaluation in CPEP triage, the patient was alert and oriented, but easily distractible and very inattentive. The patient appeared disheveled, agitated, restless, hostile and guarded, with bizarre and erratic/unpredictable behavior. The patient was sexually preoccupied, and was seen trying to touch staff inappropriately. He also appeared internally preoccupied, laughing to himself, and paranoid, constantly looking around the room in a suspicious manner. The patient’s thoughts were very disorganized and illogical, his speech was pressured with rapid rate, tangential, and hyperverbal, and his mood was euthymic with a flat affect. The patient was very uncooperative throughout the interview, requiring frequent redirecting. When asked about the events leading up to his presentation at the hospital, the patient stated “I spent the night at my father, and then I left and got lost in Harlem. Then I got on the wrong train and ended up in Queens.” When asked why he was brought to the hospital the patient reported “I don’t know” with an indifferent expression. When asked about his family, the patient became very irritable and hostile, and refused to provide any answers. The patient also admitted to marijuana use and taking Percocets (unknown dose) earlier that day. The patient admits to polysubstance use (marijuana, cocaine, opioids), and admits to using “Mushroom and Cocaine” 4 days ago in his father’s car and reports, “ I cannot remember anything that day, I was partying and everywhere I go I was rulu-lala.” The patient denied alcohol use, active auditory or visual hallucinations, and any suicidal / homicidal ideations, intent or plan. The patient denied taking any medications, and denied having any past psychiatric history or ever seeing a psychiatrist / therapist. The patient is a poor historian. The patient displays poor insight, judgement, and impulse control. The patient is an immediate danger to himself and to others. He is psychiatrically unstable, displays acute psychosis and mania, and requires CPEP admission for psychiatric observation, evaluation, and stabilization. 

Collateral information was obtained from the patient’s father (Farheed xxx-xxx-xxxx) who informed that the patient is “getting more dangerous.” He states,”my son has bad habits, hasn’t been sleeping, and uses a lot of drugs. He lives with me, but sometimes doesn’t return home, and ends up on and off the streets.” He reports his son does not eat, is “out all night,” and does not shower/bathe. He also informs that the patient has a history of Bipolar Disorder, but does not take any medications or follow up with an outpatient psychiatrist /therapist. The father also reports the patient was violent / physically aggressive with him, and last week pushed him down to the ground inside their house. The father does not feel safe with the patient at home, and feels the patient requires inpatient admission and treatment with medication.”

I also enjoyed hearing the presentations from my other classmates and hearing about their experiences from their psychiatry rotation. While my classmate, Chaya, and I were working in the CPEP (a psychiatric ER), our other classmate, Sam, was working on an inpatient psychiatric floor. She explained that while we only see the same patient for at most 2-3 days, she works with the same patients for up to 14 days. While we focused more on how to stabilize patients with acute psychosis, acute mania, or active suicidal ideation, she learned what it entails to properly manage patients and adjust their treatment regimens once they are stabilized. Just how one could compare the emergency medicine to internal medicine and say that the internal medicine reports are typically more extensive since they include all aspects of the patient’s entire hospital stay, so too the same could be said about the CPEP compared to inpatient psychiatry. Sam’s presentations included a long list of provider consults and medication changes for each patient, as she was able to follow each patient for an extended period of time. This was very interesting to see, and learning about the difference between the CPEP and inpatient psychiatry definitely added to my experience from my psychiatry rotation. 

Finally, I not only learned a lot from my patient presentations, but also from the pharmacology cards we were instructed to write. Dr. Saint Martin had us include a section of “Evidence of Efficacy” for each card, where we were tasked with researching evidence from clinical trials supporting the efficacy of the drugs we were presenting. In doing so, I found a lot of research that showed how one antipsychotic was more effective than another, and read through studies that found very limited efficacy on drugs that are commonly used. We were also tasked with outlining drug interactions for each of the drugs, which gave us a great review of pharmacology that we will definitely need for our End of Rotation Exam.