Psych Eval 2

Demographics: 56-year-old female, married, employed part-time, lives with spouse.

Visit Type: Initial psychiatric evaluation via secure audio/video telemedicine.

Reason for Visit: Worsening depressive symptoms in the setting of bipolar disorder and multiple medical comorbidities.

Chief Complaint: “My mood has been really low again, and I’m having trouble sleeping and getting motivated.”

Psychiatric Diagnosis: Bipolar I disorder, current episode depressed, moderate (F31.32).

Medical Comorbidities: Type 2 diabetes mellitus, hypertension, and hyperlipidemia.

Social Problems Addressed: Work stress, financial strain related to medical expenses, decreased social activity, and family stress.

Current Medications:

· Metformin 1000 mg PO BID

· Losartan 50 mg PO daily

· Atorvastatin 40 mg PO nightly

· No current psychiatric medications

Psychiatric History: Reports prior manic episodes characterized by approximately 7–10 days of decreased need for sleep, increased energy, rapid speech, excessive goal-directed activity, irritability, and impulsive spending that caused significant family and financial problems. Most recent manic episode was approximately 1 year ago. Currently reports several weeks of depressed mood, anhedonia, fatigue, poor concentration, decreased motivation, and insomnia. Denies current manic symptoms, psychosis, or SI/HI.

Procedures: Comprehensive psychiatric evaluation, MSE, mood-disorder assessment, medication reconciliation, metabolic-risk review, PHQ-9, suicide risk assessment, substance-use screening, and functional assessment.

Clinical Note: Patient presents with current bipolar depressive symptoms without evidence of active mania or psychosis. Medical history is significant for T2DM, HTN, and HLD, making metabolic adverse effects an important consideration when selecting treatment. She denies substance misuse and reports no current suicidal or homicidal ideation.

SOAP Note

S: Reports depressed mood, loss of interest, low energy, poor concentration, insomnia, and reduced motivation. Confirms history of distinct manic episodes with decreased sleep, increased energy, impulsivity, and functional impairment. Denies current mania, psychosis, SI, or HI.

O: Telemedicine MSE: A&O ×4, cooperative. Mood depressed; affect constricted and congruent. Speech normal rate and volume. Thought process linear and goal directed. No delusions or hallucinations observed. Insight and judgment fair.

A: Bipolar I disorder, current episode depressed, moderate. T2DM, HTN, and HLD increase concern for medication-related metabolic effects.

P: Start lamotrigine 25 mg PO daily for 2 weeks, then increase to 50 mg daily for 2 weeks, with continued gradual titration based on response and tolerability. Counsel patient to stop medication and seek prompt medical evaluation for any new rash, mucosal lesions, or systemic symptoms because of the risk of serious hypersensitivity reactions. Avoid antidepressant monotherapy due to bipolar I diagnosis. Consider an evidence-based bipolar depression agent if additional symptom control is needed, while weighing metabolic risk. Coordinate with PCP for A1c, lipid profile, BP, weight/BMI, and general medical monitoring. Encourage psychotherapy, regular sleep schedule, mood tracking, and relapse-prevention education. Safety plan reviewed.

New Psychiatric Medication: Lamotrigine 25 mg PO daily with gradual titration.

Psychotherapy during visit: No Telemedicine: Yes – audio/video Activity Time: 60 minutes Complexity: High CPT: 90792 ICD-10-CM: F31.32, E11.9, I10, E78.5