Daniel DeMarco Focused H&P #8 Psychiatry

CC: Worsening Depression and Anxiety

 

HPI: 31 year old white female, single, employed, domiciled with parents and brother, with a reported past psych hx of MDD, GAD, Trichotillomania, with a reported PMhx of IBS, GERD, Migraines Presented to Mindful Urgent Care secondary to worsening depression and anxiety and to establish psychiatric care. Patient states that she has masked her symptoms of depression and anxiety over the past 11 years by using marijuana daily. She has been in talk therapy weekly since February which she states has helped slightly. Her therapist recommended she come here for medication adjustments. Patient has been on Prozac 60mg qd initially prescribed by psychiatrist and then by primary care for over 10 years. She has also tried Zoloft in the past which she tolerated well. She states she D/C marijuana last Wednesday and since stopping her depression and anxiety have worsened significantly. She is now using CBD as she states it helps to calm her. Patient states that she has been “so down” and has been crying often these past few days. States that she doesn’t want to leave her room, has been more irritable, and that she feels that her mood is affecting her hygiene as she is losing interest in showering. She will make excuses to not see her friends, is experiencing chronic fatigue, and is hypersomnolent. Earlier today while driving she had passive suicidal ideation when she wished that a car would hit her on the way to work. She experienced a panic attack with hyperventilation and shaking at work earlier and her coworkers drove her to this facility. Patient states that her living situation often frustrates her as her older brother is a source of great stress due to his anxiety and various addictions including gambling, cocaine, marijuana, and alcoholism. Patient states that her appetite has been poor as food has been making her nauseous since D/C marijuana. Patient states that she does not exercise, but expresses interest in starting exercise once she “has the energy.” Patient at this time denies active 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 active SI/HI/PI/AH/VH. 

 

Past Psychiatric History: MDD, GAD, Trichotillomania

PMH: IBS, GERD, Migraines

Past Surgical History: None

Allergies: NKDA

Medications:

Current: Fluoxetine 60mg PO qd

Past: Sertraline

Health Maintenance:

Exercise: None

Sleep: 6h nightly

Diet: Varied but Poor Appetite since D/C Marijuana

Sexual Activity: Not sexually active at this time

Immunizations: UTD

Social History:

Marital Status: Single

Living Situation: Domiciled with Parents and Brother

Education and Employment: Works as a Secretary for a Neurosurgeon

EtOH/Drugs: EtOH rarely: 1x per month. Former Daily Marijuana User x 11 Years. Current 

CBD User.

Family History:

Mother: Migraines, Anxiety – No pharmacotherapy

Brother: Anxiety, Gambling Addiction, Alcoholism, Cocaine Addiction, Marijuana 

Dependency – No pharmacotherapy

 

ROS:

General: Admits anorexia. Denies fever, chills, weight loss, weight gain

Neuro: Denies HA, trauma, LOC, seizure activity, 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. S is a medium height, medium build woman who appears her stated age of 31yo. 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. S was slightly tremulous which she ascribed to her anxiety. She did not display any bizarre behavior.

 

3. Attitude Towards Examiner: Ms. S cooperated with the examiner and she established rapport in about three minutes.

 

Sensorium and Cognition 

 

1. Alertness and Consciousness: Ms. S was alert and could maintain her consciousness for the entirety of the interview. 

 

2. Orientation: Ms. S was oriented to person, place of the exam, the time of day and date, and the situation.

 

3. Concentration and Attention: Ms. S was attentive throughout the entirety of the interview. Ms. S gave relevant responses to questions. 

 

4. Capacity to Read and Write: Ms. S demonstrated comprehension reading and writing.

 

5. Abstract Thinking: Ms. S 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. S’s remote, recent, and immediate memory were normal.

 

7. Fund of Information and Knowledge: Ms. S’s intellectual performance was normal.

 

Mood and Affect 

 

1. Mood: Ms. S’s mood was dysphoric and anxious.

 

2. Affect: Ms. S’s affect was restricted.

 

3. Appropriateness: Ms. S’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. S’s speech pattern was normal in rate, rhythm, articulation, and fluency.

 

2. Eye Contact: Ms. S made adequate eye contact. 

 

3. Body Movements: Ms. S had mild extremity tremors that she ascribed to anxiety. She did not exhibit facial tics or decreased and slow body movements. She had a normal gait.

 

Reasoning and Control

 

1. Impulse Control: Ms. S’s impulse control was satisfactory. She did not have active suicidal or homicidal urges. 

 

2. Judgment: Ms. S had no paranoia, bizarre delusions, auditory or visual hallucinations. 

 

3. Insight: Ms. S had fair insight into her psychiatric condition and the need to take medications and attend therapy.

 

Assessment/Plan:

LS is a 31yo Female with Past Psychiatric History of MDD, GAD, and Trichotillomania complaining of passive SI, increased episodes of crying, decreased desire to leave her room, increasing isolation, decreased concern for personal hygiene, hypersomnolence, chronic fatigue, anorexia, and increasing frequency of panic attacks consistent with MDD recurrence and Panic Disorder exacerbation.

 

#MDD, Panic Disorder

– Increase Fluoxetine to 80mg PO qd for MDD, Panic Disorder

– Start Hydroxyzine 25mg 1-2 tablets PO q6h prn for Panic Disorder

– Continue weekly therapy

– Complete blood work as directed: CBC, CMP, TSH w/ Reflex T4

– Start exercise as directed

#Trichotillomania

– Continue weekly therapy 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. 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