Mrs. Darcy, a 78-year-old retired teacher, has struggled with recurrent major depressive episodes since her late 20s. It was not until 2 months ago that she started experiencing some manic symptoms. She presented tonight to the emergency room with her husband, who was increasingly concerned that Mrs. Darcy was not acting like herself.
At first, her husband noticed some restlessness; Mrs. Darcy had a hard time relaxing. It then progressed to an inability to fall asleep and stay asleep. For the past 6 weeks, she has been averaging 34 hours of sleep per night, compared to her usual 89 hours. In the past month, she has also taken on some new projects within the home. She decided to renovate their kitchen and their master bathroom and redo their backyard deck all within the same week. She has contacted numerous contractors and purchased various home improvement magazines and books but has not been able to progress further into the planning stages, as she becomes easily distracted by other things. When her husband asks her to slow down and perhaps focus on one project, she becomes irritated and yells that he never lets her do anything that she wants. He feels that she has been much more short-tempered in the past month.
In the past week or so, she has spent most of the day in church, praying. Although Mrs. Darcy is a Christian, she usually attends church only once or twice a month. She indicated to her husband that she has been going more often in the past week because she needs to repent of her past sins. She has a feeling that if she does not repent her sins, something horrible will befall her family.
On mental status examination, Mrs. Darcy appeared well groomed but dressed in a youthful, trendy style. She was annoyed at coming to the hospital, as she felt nothing was wrong with her. Her thought process was tangential, but she could be redirected with some effort. Initially, Mrs. Darcy scoffed at the question of suicide, but she later made the comment that if she had to stay in the hospital any longer, hospital staff might as well kill me now as she cannot stand to be in a prison. Throughout the assessment, she paced back and forth in the interview room.
Medically, Mrs. Darcy is relatively stable. While she has a history of hypertension and dyslipidemia, both are well-controlled with medications. Her hypothyroidism has also been stable over the past years, with her primary care physician monitoring her laboratory results regularly. She had a previous fracture of her right tibia and fibula about 10 years ago from a skiing accident that did require surgical intervention. She has struggled with chronic pain in her lower right leg as a result.
Her medications, which her husband brought in a dosette, include ramipril 5 mg qam, atorvastatin 40 mg q supper, escitalopram 15 mg qhs, lorazepam 2 mg qhs, pantoprazole 40 mg ac meals, and levothyroxine 75 mcg qam.
Her vital signs on initial presentation showed a blood pressure of 132/76 mm Hg, a heart rate of 103 BPM, and O2 saturation at 98%. The emergency physician ordered basic laboratory investigations, including complete blood count (CBC), electrolytes, creatinine, estimated glomerular filtration rate (eGFR), total bilirubin, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, and thyroid-stimulating hormone, which were all within normal limits.
The emergency physician determines that Mrs. Darcy may be at imminent risk and asks whether she should be on a psychiatric commitment order based on Mrs. Darcys comments about killing herself if she needed to remain in the hospital. She has been referred to you, the emergency psychiatric consultant, for further assessment and management of her suicide risk, mood, and behavior.
Assignment Instruction
Use the SOAP note template to complete the documentation with the information provided.
- Formulate appropriate diagnoses and design a treatment plan.
- Explain what further information you will explore to aid in accurate diagnosis.
- What other investigation will you consider narrowing down the diagnosis?
- Outline your evidence-based treatment plan.
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Requirements: soap note template