IDENTIFYING INFORMATION: The patient is a (XX)-year-old (date of birth MM/DD/YYYY) Hispanic, twice married, unemployed lady. Currently, she is staying with her ex-husband along with her 14-year-old daughter.
SOURCE OF INFORMATION: Self and previous records.
PRESENTING PROBLEMS: The patient was hospitalized at (XX) Center from MM/DD/YYYY to MM/DD/YYYY for worsening depression. She was discharged on the same medications that she was hospitalized on, namely trazodone 150 mg at bedtime and clonazepam 0.5 mg t.i.d. These are the medications started by her primary care physician a few weeks ago. The patient complains of multiple symptoms of depression. She is having frequent mood swings, sometimes several swings in one day. She thinks that overall her depression is somewhat better considering that it is summer. In winter, she states she really gets worse. She is sleeping well with the help of trazodone, while her appetite is also getting better. Prior to hospitalization, she had lost 15 pounds. She often feels tired. She cries every day. She does not feel hopeless or helpless. Her concentration is poor. She has poor memory as a result. She has difficulty making decisions. Her self-esteem is poor. She is uncomfortable around people.
The patient admits to having symptoms suggestive of mania. There have been times, lasting for up to one week, when she has been a bundle of energy with decreased need for sleep. She had racing thoughts. She would become creative and want to start multiple projects at once. She would make rash decisions. She would want to spend excessively. The patient states that probably her continued symptoms of depression are related to severe stress with her three daughters and their continued troubles with the law. The patient thinks one of her daughters has bipolar disorder. They are constantly fighting with each other, which exacerbates her stress levels. She also does not get along well with her daughters because of the above reasons, and because of the ongoing conflict with her daughters, she ended up missing quite a few days at work and eventually lost her job. The patient denies any symptoms suggestive of hypothyroidism or hyperthyroidism. She denies any symptoms of psychosis. She denies taking steroids or beta blockers.
PAST PSYCHIATRIC HISTORY: The patient has an extensive psychiatric history. Her first hospitalization was (XX)years ago because she attempted suicide. She had another hospitalization in (XXXX). In the past four years, she has had four to five other inpatient treatments. She followed up with Dr. John Doe for four years. She also followed up with Dr. Jane Doe for two months. Over a period of time, she has been tried on multiple antidepressants. She was also briefly tried on lithium. She discontinued the medication on her own after one month.
SUBSTANCE ABUSE HISTORY: The patient has not used drugs on a regular basis for more than 15 years. She does admit to using marijuana one month ago, which was again after several years of being clean, per her. She has used cocaine in the past continuously for eight months before stopping. She has never used IV drugs.
MEDICAL HISTORY: The patient is a borderline diabetic and is maintained on diet. She had complete hysterectomy because of endometriosis.
SOCIAL HISTORY: She describes having symptoms of ADHD as a child. She graduated from school. While currently she is unemployed, she was employed until recently. She has been married two times, each marriage lasting for a short period of time. She has three daughters from the two marriages. Currently, she is staying with her first ex-husband because reportedly she and her daughter were thrown out of her boyfriend’s place.
MENTAL STATUS EXAMINATION: The patient is appropriately dressed and groomed. She is cooperative and communicative. She maintains eye contact. Rapport is limited. Psychomotor activity is normal. No involuntary movement. Speech is spontaneous with normal volume and tone. She describes her mood as depressed. Her affect conveys depression. She denies any suicidal or homicidal ideations or abnormal perception or delusions. Her judgment is intact. She has insight into her illness.
DIAGNOSES:
AXIS I:
1. Bipolar disorder, mixed type.
2. Rule out major depressive disorder, moderate and recurrent.
AXIS II: Rule out borderline personality disorder.
AXIS III: Status post total hysterectomy and borderline diabetes mellitus.
AXIS IV: Severe stress in the form of multiple failed relationships and ongoing conflict with three daughters.
AXIS V: 50.
RECOMMENDATIONS:
1. The patient does not pose any imminent danger of harming herself or others; therefore, she should continue to attend the program.
2. The patient does not report any major side effects associated with Klonopin and trazodone; therefore, both should be continued at the current dose. She should be started on Depakote 250 mg at bedtime for one week and 500 mg at bedtime for one week and then 750 mg at bedtime. At that point, Depakote level will be advised. Efficacy and side effect profile of this medication was reviewed with the patient. She was also provided with information brochure on bipolar disorder and Depakote.
3. The patient will be evaluated at weekly intervals while in the program.
