Visit: Routine follow-up visit
Source and Reliability: W.C. is a reliable source
Referral: Primary healthcare provider
CC: “I feel more manic since last week.”
Objective: The patient is 32 y/o female who is dressed neatly, well groomed, and appropriately for the weather. Patient is pregnant and appears to be in mild discomfort, good posture, and eye contact. She responds to questions in a normal tone of voice.
Vital Signs: None Ht.: 65” Wt: 150 lbs lbs. BMI: 25 (patient is pregnant)
Medications: Lamotrigine 100 mg PO QHS, Melatonin as needed for insomnia; in past treated with Latuda 60 mg, zolpidem 10 mg PO QHS as needed for insomnia, Clonazepam 0.5 mg QD as needed for anxiety
HPI: Patient is a 32-year-old female, who comes in for a routine follow-up visit for bipolar disorder management. The patient is 6 months pregnant and has had manic episodes for the past 4 days. She had been doing well before this visit. She was first diagnosed with Bipolar disorder II at the age of 21. Since then she has been treated with Latuda, Zolpidem and Clonazepam. Every two weeks, she visits her OB/GYN. States that in the past 4 days, she has been getting 2-3 hours of sleep and “somehow I feel rested”. She admits to excessive spending and admits to going on a $5000 shopping spree yesterday for nursery items and baby clothing. Her husband took her credit cards and returned the majority of the purchases. She claims to be irritable and to have racing thoughts. She denies having any violent or suicidal thoughts or causing harm to herself or others. Episodes of hypomania alternate with feelings of sadness and anxiety. Last hospitalized 2 years ago due to mania. CBC, CMP, and TSH have been done at the OB office one week ago with no acute findings. Lamotrigine levels low at 2mcg/mL. Patient is employed full-time as a nail technician. Plans to start maternity leave in 1.5 months.
Location: Patient presents with anxiety, hypomania, mood swings, racing thoughts, insomnia
Duration: Symptoms of hypomania has lasted for the past 4 days. Last manic episode 2 years ago, resulting in hospitalization.
Severity: Moderate to severe. Patient with excessive spending, high energy, and insomnia interfering with daily activities
Timing: First diagnosed with Bipolar disorder at the age of 21. Per patient, she began feeling “up and down” at the age of 18. At the age of 21 was hospitalized for a manic episode.
Associate signs and symptoms: Patient with associated signs and symptoms of anxiety, sadness, insomnia, heightened energy, grandiosity, racing thoughts
Modifying factors: This patient is employed full-time and is 6 months pregnant. Increased stress related to pregnancy, getting ready house for the newborn, and full-time employment may hinder the treatment plan. Furthermore, this patient has appropriate emotional support from her husband.
Mood disorder questionnaire: Score 13 (Positive screen)
GAD-7: Score 5 ( Mild anxiety)
Past Psychiatric History: Bipolar disorder II, insomnia
Self-Harm Behavior/Suicide: W.C. denies any suicidal ideation or attempts, and denies any self-injurious behavior.
Violence: No reported history of violence.
Substance Use History: Denies .
Nicotine: Denies tobacco use and/or vaping.
Illicit Substances: Denies.
Caffeine: One cup of decaf coffee per day, no cream, no sugar. No tea or soda consumption.
Past Medical History: No significant medical history
Social/Developmental History: Development: At the age of 32, she is in Erickson’s intimacy vs isolation stage. W.C. seeks to explore and create long-term relationships with people other than family members. Patient reports no developmental delays, was born at 39 weeks, and started walking and talking on time. Employment: Works at the nail salon as a nail technician. Family: Recently married, and lives with her husband. Has one sister, lives out of state. Mother and father live about 30 minutes away. Mother has been a stay-at-home mom and never worked. Father is a retired computer engineer. Patient describes her childhood being “normal” with good emotional support whenever needed. Social: The patient works full-time and has close relationships with coworkers. ” I am a very social person”. She has two best friends with whom she communicates on a daily basis. Sexual: Started menses at age 13. Education: Graduated high school and completed some college classes. Legal: Denies. Multicultural: Asian, reports her mother and father are from the Philippines. Spirituality: Christian, goes to church once a month. Military: Denies. Leisure/Recreation: Enjoys yoga, reading novels, art, and design. Enjoys decorating her home. Weapons: Denies any weapons in the home.
Family History: Psychiatric: Mother- Generalized anxiety disorder, bipolar disorder type II; Sister- Bipolar disorder type I, Attention-deficit disorder- inattentive type; Father- unremarkable.
Medical: Mother- Hypertension, DM II. Father- Osteoarthritis. Sister- unremarkable. History of completed suicide: Denies history of complete suicide
Allergies: No known allergies
Medications: Current: Lamotrigine 100 mg PO QHS, Melatonin 6 mg PO QHS PRN. Past: Latuda 60 mg, zolpidem 10 mg PO QHS as needed for insomnia, Clonazepam 0.5 mg QD as needed for anxiety
Constitutional symptoms: Patient denies falls, fever, weakness or fatigue. Cardiovascular: Patient denies chest pain, shortness of breath, irregular heartbeats. Neurological: Patient denies seizures, syncope, disorientation, numbness, tingling, difficulty walking, or tremors. Psychiatric: Patient admits anxiety, depression, feeling irritable, anger and mood swings. Patient denies suicidal thoughts, reduced concentration, tobacco use, alcohol use, substance use, psychosis, eating disorder. Mania: Reports hypomania
Physical Exam: No physical exam was conducted. Patient seen by OB/GYN every 2 weeks, last blood draw at the OB office, Lamictal levels 2 mcg/mL (done last week). Will request labs from OB/GYN office. Did not see primary care provider in the past 2 years. Needs to establish care with primary care provider. Imaging: None.
Mental Status Exam:
General: Dressed appropriately for the weather, clothing is clean and neat, groomed well, minimal makeup.
Behavior: Good posture, sitting on the couch, animated with hand gestures. Good eye contact, pleasant and polite. Answers questions respectfully.
Speech: Fast and circumstantial
Mood: Positive for hypomania.
Affect: Restless and hyper talkative
Thought Process: Racing thoughts. Grandiosity. No hallucinations or delusions present.
Thought Content: Denies suicidal or homicidal thoughts, no violent thoughts
General Cognitive State: Alert and coherent.
Perceptions: Denies hallucinations or delusions, no paranoia feelings
Sensorium: Alert, oriented x 4.
Immediate memory– intact, patient was able to repeat “ penny, cat, table” and recall all three items at five minutes
Recent memory– intact, patient was able to recall her meals the day before and daily activities in the last day
Remote memory– intact, patient was able to recall previous address of residence and previous employment place
Insight/Judgment: Good. Patient was able to discuss the reason for her visit, was aware of her diagnosis and what medications she is on.
Summary: Patient is 6 months pregnant with hypomania in the past 2 weeks. She admits to excessive spending and admits to going on a $5000 shopping spree yesterday for nursery items and baby clothing. Presents with insomnia, irritability and anger. No hospitalizations in the past 2 years.
Goals: Patients goal is to control hypomania to avoid hospitalization and manic episodes.
Bipolar II disorder, current episode hypomanic ( F31.81)
Symptoms: Patient with abnormally increased energy and irritable mood for the past 4 consecutive days. Patient with decreased need for sleep, reports sleeping 2-3 hours per night and feeling rested. Patient with grandiosity and racing thoughts.
Major depressive disorder (F33.9)
This patient does not meet the diagnostic criteria for major depressive disorder. To be diagnosed with MDD, the patient would have had to be depressed nearly every day for the previous two weeks, which this patient denied. She still has an interest in her hobbies and daily activities. This patient presented with insomnia and sadness, but she does not meet the full MDD criteria. This patient also denied feelings of worthlessness or guilt and difficulties thinking, concentrating, or making decisions (APA, 2013).
Generalized Anxiety Disorder (F41.1)
This patient does not meet the diagnostic criteria for generalized anxiety disorder. This patient denies excessive worrying and difficulty controlling worrying. Furthermore, current anxiety episodes are explained by bipolar disorder, hypomanic episode. Some of the positive symptoms of anxiety that the patient experiences include insomnia, irritability, and nervousness; which all can be contributed to hypomanic episode.
Risk Factor Analysis: The client is at moderate risk of self-harm due to hypomania and insomnia, which could lead to a manic episode. Protective factors: The patient is seeking assistance and has been closely monitored by a psychiatrist, a licensed clinical social worker, and an OB/GYN. She has been compliant with prescribed treatment and has appropriate emotional support from her husband.
Psychiatric/Mental Health Plan:
- Start Olanzapine 2.5 mg PO QHS
- Lamotrigine levels every 4 weeks
- Patient to continue weekly sessions with LCSW for CBT
- Follow up with OB/GYN
Health Promotion: Encouraged physical activity as tolerated by the patient. Encouraged patient to take frequent walks. Sleep hygiene was discussed with the patient. Limit brain-stimulating activities 1 -2 hours prior to scheduled bedtime.
RTC: Follow up in 1 week at the clinic
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of
mental disorders (5th ed.). Washington, D. C.: American Psychiatric Publishing
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