Daniel DeMarco Focused H&P #1 Psychiatry

CC: Worsening “alternating periods of highs and lows”
HPI: 23 year old white female, in a relationship, Pre-Nursing Student, domiciled with parents
and grandparents, with a reported past psych hx of General Anxiety Disorder and Depression,
with a reported PMhx of Graves’ Disease treated with Radioactive Iodine and now
Hypothyroidism, Celiac Disease, Presented to Mindful Urgent Care secondary to worsening
alternating periods of “highs and lows” and to establish psychiatric care. Patient states that she
has fluctuations in her mood that she feels are cyclical. She will feel “highs” for approximately
10d in which she experiences racing thoughts, will talk very fast and switch topics often, will
impulsively shop online, will experience grandiosity and insomnia. Patient also reports that she
has been hypersexual in the past during one of these 10d episodes, with multiple partners over
the course of a few days. Patient states she finds that she is unable to concentrate during these
episodes and will often try to distract herself with “mindless” background television or walking.
She states that if she is alone and not doing anything, the racing thoughts bother her because
she cannot keep up with them. The patient states that these episodes alternate with “low
periods” that she tries to “pull herself out/snap out of.” The patient states that she doesn’t
want to feel like people need to help her. During the “lows” she states she will cry a majority of
the time, notices increased irritability, and will be increasingly anxious. She finds that she will
isolate herself, making excuses to avoid friends and family. She experiences anhedonia in that
she previously used to enjoy watching documentaries but now gets no joy from doing such a
thing. She states her anxiety often latches onto social situations where she often overthinks
about peoples’ perceptions of her and her actions. She states that if she is in class and needs to
use the restroom she will avoid getting up in the middle of class because she will think “What
will they think of me if I’m the only person to get up? Will people look at me?” She states that
she does get panic attacks occasionally, experiencing dry mouth, sweating, heart racing.
Despite these symptoms, the patient reports that she is keeping up with her school work and
reports that she recently scored an 88 and a 100 on two of her assignments. She states that she
is experiencing passive suicidal ideation, and in the past has expressed to her Aunt and StepFather “I’d rather not be here.” She has no lifetime suicide attempts and denies intent or plan
presently. She has been in therapy in the past for anxiety and depression but is currently not
seeing a therapist. Patient mentioned that at one point one therapist diagnosed her with
Bipolar disorder, though she discontinued seeing that therapist because the patient moved.
Patient reports that she has suffered from emotional/verbal trauma from her father whom was
an alcoholic. Furthermore, the patient recently learned of her cousins suicide a few weeks ago.
She also reports sexual abuse from a friend of her father’s when she was younger. After the
abuse, the patient began self-harming with cutting. The last time she performed this behavior
was 12-13 years old. Patient also states that when she was younger she has engaged in binging
and purging but no longer performs this behavior nor thinks about it. She has never tried
medications for her diagnoses. She has tried CBD oil, vitamins, and Adaptogenic Powders with
no relief. Patient states she has a history of Graves’ treated with Radioactive Iodine 4-5 years
ago and that she is now Hypothyroid. Was prescribed Synthroid but hasn’t taken it since
January. Patient states this is due to her move and that she requires a new PMD. Patient
endorses hair loss but denies weight gain and cold intolerance. Patient reports that she has a
Paragard Copper IUD and is sexually active with one partner. Patient admits fleeting thoughts of
passive thoughts of SI. Patient admits manic s/sx such as racing thoughts, grandiose beliefs,
irritability, elation, euphoria, inability to focus, past history of hyper sexual acts, hyper verbal
speech pattern, decreased sleep pattern with increase in energy. Patient adamantly denies ever
attempting suicide in her life time, denies ever being hospitalized for mental health issues, and
at this time denies HI/PI/AH/VH or illicit drug use. Admits social EtOH use 1x weekly consuming
3-4 drinks and tobacco use: vaping x 2 years. Former cigarette smoking x 5-6 years, 2-3
cigarettes per day.
Past Psychiatric History: Generalized Anxiety Disorder, Depression
PMH: Graves’ Disease treated with Radioactive Iodine and now Hypothyroidism, Celiac Disease
Past Surgical History: None
Allergies: NKDA
Medications:
Current: Paragard Copper IUD
Past: None
Health Maintenance:
Exercise: 3-4x/weekly. Aerobic and anaerobic
Sleep: 5h nightly
Diet: Pescatarian
Sexual Activity: Sexually Active with One Male Partner. Has Paragard Copper IUD and
uses Condoms
Immunizations: UTD
Social History:
Marital Status: Single
Living Situation: Domiciled with Mother, Step-Father, and Grandparents
Education and Employment: In College for Pre-Nursing
EtOH/Drugs: Social EtOH: 1x weekly – 3 or 4 drinks maximum; Tobacco Use: Current
Vaping x 2 years; Former Cigarette User x 5-6 years, 2-3 cigarettes daily
Family History:
Father: Depression, Alcoholism, Cocaine Addiction
Mother: Anxiety, Depression treated with Lexapro
Sister: Anxiety, Depression treated with Prozac
Maternal Grandmother: Anxiety, Depression

ROS:
Psychiatric: Admits feelings of helplessness, hopelessness, passive SI.
Mental Status Exam:
General
1. Appearance: Ms. L is a medium height, medium build woman who appears her stated age of
23yo. She has no scars on her face or hands. Her hygienic state was clean and her clothes well
kept.
2. Behavior and Psychomotor Activity: Ms. L had no psychomotor agitation, retardation or
bizarre behavior.
3. Attitude Towards Examiner: Ms. L was pleasant and cooperated with the examiner and she
established rapport in about five minutes.
Sensorium and Cognition
1. Alertness and Consciousness: Ms. L was alert and could maintain her consciousness for the
entirety of the interview.
2. Orientation: Ms. L was oriented to person, place of the exam (Mindful Urgent Care), the time
of day (Morning) and date (9/11/19), and the situation (“I came in because I have alternating
periods of feeling good and then feeling down”).
3. Concentration and Attention: Ms. L was attentive throughout the entirety of the interview.
She was able to concentrate and successfully complete the “Serial 7 Test.” Ms. L gave logical,
organized responses to questions. She did not stray to other topics.
4. Capacity to Read and Write: Ms. L demonstrated comprehension reading and writing.
5. Abstract Thinking: Ms. L used a few simple metaphors in English to explain things and clarify
her thoughts. She could mentally perform simple mathematical calculations including addition
(10 + 4 = 14), subtraction (9-5 = 4), and multiplication (1 x 100 = 100). Her ability to recognize
patterns among groups of things was intact, answering “Red” when questioned what is the
same between a fire hydrant, an apple, and a stop sign? Her ability to use deductive reasoning
was intact, answering “Bob’s cupboard has three shelves” when told the following facts: a) Bob
has a green cupboard b) All green cupboards have three shelves c) Lisa has a yellow cupboard,
and asked to draw a conclusion from the statements. When asked to interpret “Those who live
in a glass house should not throw stones,” the patient stated that it meant that people should
not criticize others because everybody has faults of their own.
6. Memory: Ms. L’s (Patient responded “Levittown” when asked where she lived when growing
up), recent (Patient responded ball, dog, and pencil when asked to recall the things I asked him
to remember 5 minutes prior), and immediate memory (Patient repeated ball, dog, and pencil)
were normal.
7. Fund of Information and Knowledge: Ms. L’s intellectual performance was normal (She
responded “Donald Trump” when asked who the president of the US was and “Albany” when
asked what the capital of NY is) and consistent with her level of education (Pre-Nursing
Student).
Mood and Affect
1. Mood: Ms. L’s mood was dysphoric.
2. Affect: Ms. L’s affect was restricted.
3. Appropriateness: Ms. L’s mood and affect were consistent with the topics she discussed. She
exhibited multiple episodes of crying during the interview. She did not exhibit labile emotions
or angry outbursts.
Motor
1. Speech: Ms. L’s speech pattern was normal in rate, rhythm, articulation, and fluency.
2. Eye Contact: Ms. L made adequate eye contact.
3. Body Movements: Ms. L did not exhibit extremity tremors, facial tics or decreased and slow
body movements. She had a normal gait.
Reasoning and Control
1. Impulse Control: Ms. L’s impulse control was satisfactory. She did not have active suicidal or
homicidal urges.
2. Judgment: Ms. L had no paranoia, bizarre delusions, auditory or visual hallucinations. When
asked what the patient would do if he were sitting in a movie theater and there was a fire, she
responded “run.” When asked what she would do if she were to find a stamped, addressed
envelope on the sidewalk, she responded “pick it up and put it in the mailbox.”
3. Insight: Ms. L had fair insight into her psychiatric condition and the need to take medications
and attend therapy. When asked why she required psychiatric care she responded “I have been
experiencing these up and downs in my mood and it has been affecting my life.”
Assessment/Plan:
ML is a 23yo Female with Past Psychiatric History of GAD and Depression complaining of history
of cyclical mood fluctuations involving manic symptoms like racing thoughts, increased rate of
speech, rapid changing of topics, impulsive behaviors, grandiosity alternating with periods of
passive SI, increased crying, isolation, anhedonia, and increased irritability consistent with
Bipolar II Disorder.
#Bipolar II Disorder
– Start Lamotrigine 25mg 1 tablet PO qd x 7 days, then 2 tablets PO qd x 7 days, then 3 tablets
PO qd x 7 days, then 4 tablets PO qd x 7 days; Side effects discussed in detail and patient
informed to check for rashes daily
– Start therapy as directed – Referral List Given
– Complete blood work as directed: CBC, CMP, TSH w/ Reflex T4
– Continue exercise as directed
F/u in 4 weeks
At this time, it is deemed that the patient does not pose a threat to self or others, and does not
present with any acute psychotic features. Patient is deemed psychiatrically stable and does not
merit further acute psych intervention. Patient is to be given a follow up appointment here at
Mindful Urgent Care upon d/c. The patient also displays adequate impulse control, insight and
judgement. SE and benefits > risks discussed with patient. Patient agreeable with tx plan.
/s/ Daniel DeMarco, PA-S
Physician Assistant Student
Differential Diagnosis:
1. Bipolar II Disorder: Patient reports manic episodes (grandiosity, euphoria, racing
thoughts, easily distracted, impaired judgment, hyperactivity, pressured speech, insomnia,
impulsivity) that last approximately 10 days and cycle with depressive episodes. Patient
is 23yo and the average age of onset is 20s-30s. She does not experience marked
impairment of social/occupational functioning and has never been hospitalized.
2. Bipolar I Disorder: Signs and symptoms as reported above but less likely because she
does not experience marked impairment of social/occupational functioning and has never
been hospitalized (those features are common in Bipolar I Disorder).
3. Cyclothymic Disorder: This is similar to Bipolar II Disorder, though the periods of
elevation and depression in mood are milder. The symptoms do not meet the criteria for
hypomania and the symptoms do not meet the criteria for major depressive disorder. This
occurs for at least a 2 year period and the patient cannot be symptom-free for longer than
2 months at any time. This diagnosis is less likely because the patient meets criteria for
mania/hypomania and major depressive disorder.
4. Major Depressive Disorder: The patient currently presents in one of her “lows” and meets
clinical criteria for MDD. It is possible that she exaggerated/feigned her reporting on her
manic symptoms and that this is truly just MDD.
5. Substance-Induced Mood Disorder: The patient experiences alternating “highs” and
“lows.” The manic and/or depressive symptoms that she reports could be the result of
drug use that the patient intentionally did not report. Potential drugs may include PCP,
cocaine, stimulants, corticosteroids, etc. While plausible, this is less likely given the
patients appearance and behavior, the interview, etc.