Psychiatric Evaluation ER

Subjective:
Date & Time of Evaluation:
February 9, 2026, 00:32

Accompanied By:
No information available regarding accompaniment.

Chief Complaints:
"My hand’s so bad I can’t work. I have severe pain in multiple joints."

History of Present Illness (HPI):
The patient presents with polyarthropathy, reporting severe pain and functional impairment predominantly in the right hand, particularly affecting the fourth digit metacarpophalangeal joint. The onset of symptoms was noted at least a couple of weeks ago, with progressive worsening and spread of pain to additional joints including the left hand, toe, knee, and back. The patient describes daily progression of symptoms and significant difficulty performing occupational tasks as a construction worker, specifically an inability to grasp tools, resulting in concern for potential job loss. The patient has been using acetaminophen and nonsteroidal anti-inflammatory medications without symptomatic relief. There is a history of cutaneous plaques on the chest. The patient is awaiting a specialist appointment on April 9th. Current stressors include occupational insecurity due to functional impairment. The patient reports abstinence from alcohol and recent weight loss. There is no mention of a formal support system. Compliance with over-the-counter analgesics is reported; no disease-modifying antirheumatic drugs or other prescribed treatments have been initiated prior to this visit.

Past Psychiatric History:
- Diagnoses: No psychiatric diagnoses reported.
- Prior hospitalizations: No prior psychiatric hospitalizations reported.
- Suicide attempts or self-harm: No history of suicide attempts or self-harm reported.
- History of aggression/violence: No history of aggression or violent behavior reported.
- History of psychiatric care or therapy: No prior psychiatric care or therapy reported.

Substance Use History:
- Alcohol: No (Patient is staying off alcohol)
- Drugs: No
- Intoxication or withdrawal symptoms: None reported
- Tobacco or vaping: No information available

Medical History:
- Chronic illnesses: No chronic medical conditions reported.
- Medications (including psychotropics): Acetaminophen and nonsteroidal anti-inflammatory medications used for joint pain.
- Allergies: No allergies reported.

Medications:
Acetaminophen and nonsteroidal anti-inflammatory medications, dosages and frequencies not specified.

Family History:
No relevant family history provided.

Social History:
The patient works in construction and reports significant occupational impairment due to joint pain. No further details regarding living situation, education, or relationships provided.

Objective:
Mental Status Examination (MSE):
| Domain | Findings |
|--------|----------|
| **Appearance** | Neat |
| **Behavior** | Cooperative |
| **Speech** | Normal |
| **Mood** | "I feel frustrated and in pain" |
| **Affect** | Congruent |
| **Thought Process** | Logical |
| **Thought Content** | No abnormal content |
| **Perception** | No hallucinations |
| **Cognition** | Alert, oriented to person, place, and time |
| **Insight** | Good |
| **Judgment** | Intact |

ER Course:
- Collateral from EMS/family/police: No collateral information obtained from emergency medical services, family, or police.
- Labs / Toxicology / Imaging: Blood work reviewed; no alarming findings noted.
- Medications given in ED: Intravenous methylprednisolone administered.
- Response to treatment: No immediate response documented during the encounter.

Vital Signs:
No vital signs documented.

Physical Examination:
Examination reveals tenderness and swelling over the metacarpophalangeal joints, most pronounced at the fourth digit of the right hand. Similar changes are observed in the left hand. The patient demonstrates pain with movement and functional impairment of the right hand.

Test Results:
Blood work reviewed and did not show anything alarming. No additional laboratory, imaging, or diagnostic test results documented.

Assessment:
Risk Assessment:
- **Suicidal Ideation:** No
- **Plan:** 
- **Intent:** 
- **Means:** 
- **Homicidal Ideation:** No
- **Target/Plan:** 
- **Gravely Disabled:** No
- **Violence Risk:** Low

Plan:
Disposition:
- **Admitted to Psychiatry:** 
- **Transferred to Facility:** 
- **Discharged with Plan:**
    - Safety plan reviewed: 
    - Outpatient follow-up: Awaiting specialist appointment with rheumatology on April 9th.
    - Referral made to: Rheumatology