Psychiatric Crisis Encounter

Subjective:
Chief Complaint :
"I do not want to take my medications."

History of Present Illness (HPI):
Evelyn Brooks was evaluated due to an episode of verbal and physical aggression. The onset of the crisis was acute, occurring during the current encounter. She was observed pacing, screaming profanities, and exhibiting agitation and confrontational behavior. The triggering event appeared to be her being informed about receiving her medications, which escalated her aggression. Early warning signs included her heightened agitation and verbal outbursts. Current coping attempts were not evident as she was unable to be de-escalated despite multiple verbal interventions by staff. Suicidal ideation: No. Homicidal ideation: No. Hallucinations or delusions present: No. Substance use related to crisis: Not mentioned. Support system involvement: Not mentioned. Past crisis history and management strategies: Not mentioned.

Summary of Presenting Crisis:
Evelyn Brooks is currently experiencing a full crisis characterized by verbal and physical aggression. Risk factors identified include her inability to de-escalate and heightened agitation. Protective factors were not identified during this encounter. 

Communication Preferences
- Patient best responds to: Not mentioned.
- Approaches/words to avoid: Not mentioned.

Chief Complaint:
She exhibits verbal and physical aggression, including screaming profanity and confrontational behavior.

Objective:
Mental Status Exam (MSE):
- Appearance: Disheveled and agitated.
- Behavior: Pacing, confrontational, and physically aggressive.
- Speech: Loud, rapid, and profane.
- Mood: Agitated.
- Affect: Irritable and labile.
- Thought Process: Disorganized.
- Thought Content: No evidence of delusions or preoccupations.
- Perceptions: No hallucinations observed.
- Insight/Judgment: Poor.
- Orientation: Alert and oriented to person, place, and time.

Behavioral Observations:
- Crisis stage: Full Crisis.
- Observable triggers or environmental stressors: Being informed about receiving her medications.

Vitals:
- Vitals: Not mentioned.

Assessment:
Safety Risk Assessment:
- Suicide Risk: Low.
- Homicide Risk: Low.
- Gravely disabled / unable to care for self: Yes.

Diagnostic Impression:
- Disruptive Mood Dysregulation Disorder (ICD code: F34.81).
- Acute Agitation (ICD code: R45.4).

Clinical Judgment of Risk:
- Crisis severity: Severe.
- Immediate safety concern: Yes.

Plan:
- Stage-based intervention used: Emergency treatment order administered.
- De-escalation strategies employed: Multiple verbal interventions attempted but unsuccessful.

Safety Plan
- Contract for safety: No.
- Means restriction discussed: No.
- Emergency contacts informed: No.
- Patient agrees to safety plan: No.

Disposition
- Admit to psychiatric unit.

Medications
- Olanzapine 10 mg intramuscularly administered.
- Diphenhydramine 50 mg intramuscularly administered.

Referrals
- Not mentioned.

Follow Up
- Continue to monitor closely.