Daniel DeMarco Focused H&P #4 Psychiatry

CC: “Suffering from severe depression and extreme anxiety”
HPI: 34 year old hispanic female, married, disabled 2/2 motor vehicle collision, domiciled with
wife, daughter, and wife’s grandparents, with a reported past psych hx of Generalized Anxiety
Disorder, Major Depressive Disorder with single previous suicide attempt by cutting in July 2014
with subsequent 10 day hospitalization in North Carolina, Post Traumatic Stress Disorder, Social
Phobia, Panic Disorder, and ADHD, with a reported PMhx of Chiari Malformation for which she
underwent Brain Surgery in 2010, subsequent history of seizures with last reported seizure 3
years ago, iron-deficiency anemia, chronic fatigue, chronic pain 2/2 motor vehicle collision,
peptic ulcer disease, and GERD, Presented to Mindful Urgent Care secondary to “suffering from
severe depression and extreme anxiety” and to establish psychiatric care. Patient reports that
she has suffered from anxiety and depression x years. Patient states that her symptoms are
worsening. She is currently not in therapy. She recently obtained health insurance and is now
beginning to seek care for her various diagnoses. She reports that she is isolating herself from
friends and family, she is experiencing anhedonia as she used to enjoy drawing/writing and no
longer finds it pleasurable, is noticing decreased focus/concentration, is noticing decreased
libido, and is experience insomnia 2/2 to ruminating on negative thoughts. Patient states that
she is chronically tired and sleeps in 20-30 minute bursts throughout the night but will end up
waking up early the following day and not feeling well-rested. She reports that her appetite is
“non-existent” but denies food restriction, binging, or purging. Patient reports that she is having
panic attacks at a minimum of 2x/week, experiencing heart racing, the feeling of being unable
to breathe, feeling as though she will pass out, and then experiencing agitation when her wife
tries to console her during these episodes as there is “nothing she can do to help.” Patient
reports that she is always anxious and feels like something bad will happen and finds that her
worries exhaust her. She states that she feels “on edge” and reports that she often is shaking
and nauseous. Patient reports trauma as her mother is Bipolar and previously suffered from
alcoholism as well as a cocaine addiction. Furthermore patient reports that she was in an
abusive relationship with her first wife, who would mentally and physically abuse her. The
patient’s first wife would also try and keep the patient away from her 11 year old daughter and
isolate the patient from the rest of her family. Patient reports that she has nightmares but will
wake up and cannot recall what they are about. She states that will occasionally have
flashbacks but fewer since she had been in therapy. The patient reports that this trauma and
the depression that ensued is what prompted her suicide attempt. Patient states that she
experiences social phobia, explaining that she will experience sweating, flushing of the face,
tremors, and trembling speech when involved in social situations. She will often find herself
thinking “What if they are judging me?” Patient reports that she will occasionally experience
hyper bursts due to her ADHD. She states that when living in North Carolina she has been in
CBT therapy for her multiple diagnoses for five years previously, which she found helpful. She
also reports that she had seen a psychiatrist and in the past has used Lisdexamfetamine for her
ADHD, Clonazepam for her GAD, and Duloxetine, Fluoxetine, Sertraline, and Escitalopram for
Depression. She states that the medications typically work for a few months to a year and then
they become ineffective. She states she will contact her psychiatrist/her pharmacy to obtain a
full list of medications she has trialed. She reports that she exercises 3-4x per week and has
taken up meditation to attempt to alleviate some of her symptoms. Patient states she has 11
year old daughter and she tries “to hold it together” for her and is currently married to new
wife who is very supporting and reports no relationship abuse. Patient states she has no male
sexual partners and is not attempting to become pregnant. Patient admits fleeting thoughts of
passive suicidal ideation. Patient reports past history of single suicide attempt in July 2014 by
cutting and was subsequently hospitalized in North Carolina for 10 days. Patient at this time
denies active thoughts of active SI, with no intent or plan. Patient adamantly denies any manic
s/sx such as grandiose beliefs, irritability, changes in or inappropriate social behaviors, elation,
euphoria, hyper sexual acts, hyper verbal speech pattern, decrease sleep pattern with increase
in energy. At this time the patient denies HI/PI/AH/VH or illicit drug use/EtOH use. Patient
reports that she is a former cigarette smoker x 10 years, 1/2 pack per day. Reports she is
currently using the Juul e-cigarette x 8 months.
Past Psychiatric History: Generalized Anxiety Disorder, Depression
PMH: Chiari Malformation for which she underwent brain surgery in 2010, Seizures 2/2 brain
surgery with last reported seizure 3 years ago, Chronic Fatigue, Chronic Pain 2/2 Motor Vehicle
Collision, Peptic Ulcer Disease, GERD
Past Surgical History: Generalized Anxiety Disorder, Major Depressive Disorder with single
previous suicide attempt by cutting in July 2014 with subsequent 10 day hospitalization in
North Carolina, Post Traumatic Stress Disorder, Social Phobia, Panic Disorder, and ADHD
Allergies: NKDA
Medications:
Current: Gabapentin 600 bid for Nerve Pain, Tramadol 50mg prn for Pain, Prilosec OTC
for GERD, Peptic Ulcer Disease
Past: Lisdexamfetamine, Clonazepam, Duloxetine, Fluoxetine, Sertraline, Escitalopram,
Other Unknown Antidepressants – Patient will obtain records
Health Maintenance:
Exercise: 3-4x/weekly. Aerobic and anaerobic
Sleep: Total 3h nightly in 20-30 min. bursts
Diet: Varied
Sexual Activity: Sexually Active with One Female Partner. Patient denies Male Partners
and reports that she is not otherwise looking to become pregnant.
Immunizations: UTD
Social History:
Marital Status: Married
Living Situation: Domiciled with Wife and Daughter
Education and Employment: Currently Disabled 2/2 Injuries Sustained in Motor Vehicle
Collision
EtOH/Drugs: No EtOH use. Former Cigarette Use: 10 years, 1/2 Pack Per Day Current
Juul
User: x 8 months
Family History:
Mother: Bipolar Disorder, ADHD, Anger Problems, Alcoholism, Cocaine Addiction, PTSD.
She has been treated with Lithium in the past, Trintellix, and Latuda
Maternal Grandfather: Liver Problems
Maternal Grandmother: DM, HTN
ROS:
General: Admits weight loss. Denies fever, chills, weight gain, anorexia
Neuro: Admits seizure activity – last seizure 3y ago, trauma 2/2 Motor Vehicle Collision.
Denies HA, LOC, developmental delays
HEENT: Denies change in vision, hearing, pruritus, photo/phonophobia, neck pain,
runny
nose, ear pain, congestion, sore throat
CV: Denies shortness of breath, sweating, color changes with feeding, chest pain,
palpitations, history of murmur, fainting, or dizziness with activity
Respiratory: Denies wheezing, shortness of breath, cough
GI: Denies nausea, vomiting (bloody/bilious), diarrhea, constipation, hematemesis,
hematochezia, or melena
GU: Denies dysuria, frequency, urgency, hematuria
Endo: Denies polyuria/polydipsia, heat/cold intolerance, growth pattern abnormalities
MS: Denies myalgias, arthralgias, trauma, limp, weakness
Skin: Denies rashes, bruising, petechiae
Psychiatric: Admits feelings of helplessness, hopelessness, passive SI. Denies active SI,
HI, auditory hallucinations, visual hallucinations, paranoia
Mental Status Exam:
General
1. Appearance: Ms. L is a short, underweight woman who appears her stated age of 34yo. She
has no scars on her face. She has bilateral vertical scars on her forearms from her suicide
attempt. Her hygienic state was clean and her clothes well kept.
2. Behavior and Psychomotor Activity: Ms. L was slightly tremulous which she ascribed to her
anxiety. She did not display any bizarre behavior.
3. Attitude Towards Examiner: Ms. L cooperated with the examiner and she established rapport
in about two 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, the time of day and date, and
the situation.
3. Concentration and Attention: Ms. L was attentive throughout the entirety of the interview.
Ms. S gave relevant responses to questions.
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. Her ability to use
deductive reasoning was intact.
6. Memory: Ms. L’s remote, recent, and immediate memory were normal.
7. Fund of Information and Knowledge: Ms. L’s intellectual performance was normal.
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 was slightly tremulous which she ascribed to her anxiety. She did
not display any 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.
3. Insight: Ms. L had fair insight into her psychiatric condition and the need to take medications
and attend therapy.
Assessment/Plan:
LL is a 34yo Female with Past Psychiatric History of Generalized Anxiety Disorder, Major
Depressive Disorder with single previous suicide attempt by cutting in July 2014 with
subsequent 10 day hospitalization in North Carolina, Post Traumatic Stress Disorder, Social
Phobia, Panic Disorder, and ADHD complaining of isolation, anhedonia, decreased
focus/concentration, decreased libido, insomnia, rumination, anorexia, and increasing panic
attacks consistent with recurrence of MDD and exacerbation of GAD, Social Phobia, and Panic
Disorder.
#MDD, GAD, Social Phobia, Panic Disorder, ADHD
– Start Escitalopram 5mg PO qam for MDD, GAD, Social Phobia, Panic Disorder
– Start Mirtazapine 7.5mg PO qhs for MDD, Insomnia
– Will consider Vortioxetine in the future for ADHD
– Start therapy as directed – Referral List Given
– Complete blood work as directed: CBC, CMP, TSH w/ Reflex T4
– Continue exercise as directed
#PTSD
– Continue therapy as directed – Referral List Given
F/u in 2 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. At this time, the patient does not present an immediate threat
to self or others. 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