Daniel DeMarco Focused H&P #3 Psychiatry

CC: “I don’t want to get out of bed, have no motivation, and my anxiety has increased”
HPI: 34 year old Portuguese female, in a relationship, employed, domiciled with father, brother,
sister-in-law, and niece, with a reported past psych hx of opiate painkiller substance abuse >10
years, with no reported PMhx, Presented to Mindful Urgent Care secondary to feelings of not
wanting to get out of bed, decreased motivation, anxiety and to establish psychiatric care.
Patient states she got “in trouble” for possession of opiate pain killers and THC vaporizer in
November 2018. She is on Suboxone 8/2 tid since February 2019 which has been helping.
Patient reports she has not used any drugs/EtOH since February 2019. She has been in therapy
since February 2019 and is currently in 2 group counseling sessions per week and a one-on-one
therapy session weekly. Patient states that she has been feeling like she “can’t get out of bed,”
that her motivation has decreased, that she is procrastinating, and is occasionally tardy to work
as a part-time waitress. She states that she is unsure for how long she has felt this way because
she never dealt with her emotions. She states “I hid my feelings through drug use,” and that
“pills took over my life.” Patient states she has been isolating herself physically as well as not
answering the phone. She has noticed fatigue and decreased focus. States that she has trouble
sleeping, often falling asleep around 3:30AM. She states she is constantly “overthinking” and
thinks about the worst possible outcome in situations. Patient also reports occasional panic
attacks that manifest as racing heart, sweating, palpitations. She states that she has been
spending a lot of money shopping but feels that this is because she is transferring her addiction
to substances to another outlet. Patient admits history of multiple traumas: Her father had
alcoholism and was physically and mentally abusive. Her mother had an affair and walked away
from the family when the patient was 14 years old. The patient states she felt that her father
especially “took it out on her” because she looked like her mother. Patient also reports history
of being robbed at gunpoint in her early 20s. She states that memories of these previous
traumas make her “emotional” and she will experience flashbacks and occasionally nightmares.
She states she tries not to talk about these incidents. Patient at this time denies active or
passive thoughts of SI, with no intent or plan. Patient adamantly denies any manic s/sx such as,
racing thoughts, grandiose beliefs, irritability, changes in or inappropriate social behaviors,
elation, euphoria, unable to focus, hyper sexual acts, hyper verbal speech pattern, decrease
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
SI/HI/PI/AH/VH or drugs/etoh use.
Past Psychiatric History: Opiate Painkiller Substance Abuse >10 years
PMH: None
Past Surgical History: None
Allergies: NKDA
Medications:
Current: Suboxone 8/2 SL tid
Past: None
Health Maintenance:
Exercise: Walks 5 days weekly
Sleep: 4h nightly
Diet: Varied
Sexual Activity: Sexually Active with Boyfriend. Denies OCP use. Uses condoms
occasionally.
Immunizations: UTD
Social History:
Marital Status: Not Married but In a Relationship
Living Situation: Domiciled with Father, Brother, Sister-in-Law, Niece
Education and Employment: Part-Time Waitress
EtOH/Drugs: Former Social EtOH use. Currently no EtOH use. Former Opiate Painkiller
User Since Early 20s. Patient reports she has been sober since 02/2019.
Family History:
Father: Alcoholism
ROS:
Psychiatric: Admits feelings of helplessness, hopelessness.
Mental Status Exam:
General
1. Appearance: Ms. C is a medium height, overweight woman who appears her stated age of
34yo. 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. C had no psychomotor agitation, retardation or
bizarre behavior.
3. Attitude Towards Examiner: Ms. C was pleasant and cooperated with the examiner and she
established rapport in about five minutes.
Sensorium and Cognition
1. Alertness and Consciousness: Ms. C was alert and could maintain her consciousness for the
entirety of the interview.
2. Orientation: Ms. C was oriented to person, place of the exam (Mindful Urgent Care), the time
of day (Morning) and date (9/10/19), and the situation (“I came in because I have been
depressed”).
3. Concentration and Attention: Ms. C was attentive throughout the entirety of the interview.
She was able to concentrate and successfully complete the “Serial 7 Test.” Ms. C gave logical,
organized responses to questions. She did not stray to other topics.
4. Capacity to Read and Write: Ms. C demonstrated comprehension reading and writing.
5. Abstract Thinking: Ms. C 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. C’s remote (Patient responded “Smithtown” 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. C’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 employment (Part-Time
Waitress).
Mood and Affect
1. Mood: Ms. C’s mood was dysphoric and anxious.
2. Affect: Ms. C’s affect was restricted.
3. Appropriateness: Ms. C’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. C’s speech pattern was normal in rate, rhythm, articulation, and fluency.
2. Eye Contact: Ms. C made adequate eye contact.
3. Body Movements: Ms. C 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. C’s impulse control was satisfactory. She did not have suicidal or
homicidal urges.
2. Judgment: Ms. C 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. C 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
very depressed and anxious lately and it is affecting my life.”
Assessment/Plan:
AC is a 34yo Female with Past Psychiatric History of Opiate Painkiller Substance Abuse >10
years complaining of not wanting to get out of bed, decreased motivation, isolation,
ruminating, and anxiety consistent with Major Depressive Disorder.
#MDD
– Start Fluoxetine 20mg PO qd
– Start Hydroxyzine 25mg 2 tablets q6h prn for anxiety/difficulty sleeping
– Continue 2x/weekly group therapy and 1x/weekly one-on-one therapy
– 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. Major Depressive Disorder: Patient has depressed mood and anhedonia with > or = to 5
associated symptoms almost every day for most of the days for > or = to 2 weeks. Her
symptoms cause her distress and impair functioning related to work (e.g. tardiness).
2. Bipolar Disorder: Patient may be in the depressive phase of her Bipolar disorder. This is
less likely as the patient denies hypomanic/manic symptoms.
3. Persistent Depressive Disorder: Patient states she may have been feeling this way longer
but “hid her feelings” through drug use. Persistent depressive disorder is defined as
chronic depressed mood for >2 years in adults that may include symptoms of chronic
major depression. This diagnosis is plausible.
4. Generalized Anxiety Disorder: Patient reports that she is constantly “overthinking” and
thinks of the worst possible outcomes in situations. She is experiencing fatigue, difficulty
concentrating, and sleep disturbance. She is having panic attacks. This diagnosis is less
likely as she states that she does not have the excessive anxiety or worry for a majority of
days and she doesn’t meet the time period necessary (> or = 6 month period) for this
diagnosis.
5. Posttraumatic Stress Disorder (PTSD): Patient reports history of multiple traumas (e.g.
physical abuse from father, robbed at gunpoint) and reports reliving, flashbacks, and
occasional nightmares. She reports that the re-experiencing has gone on for >1 month.
This diagnosis is less likely because she does not report it as the cause of her mood
alteration (depression), does not experience angry outbursts, irritable behavior, or
avoidance of stimuli associated with the traumatic event.