Please reply to the discussion post below.
Name: J.B
DOB: 11.7.1987
Primary cod
Please reply to the discussion post below.
Name: J.B
DOB: 11.7.1987
Primary code: 90792
Ethnicity: Caucasian
Gender: Female
HT: 5’3
WT: 270 lbs.
Sources of information: Patient
Subjective:
CC: “my primary doctor made me come”
HPI: Ms. J.B is a 36-year-old female patient that presents via video conference for a follow-up visit. Since her last visit she reports “my primary doctor made me come”. She states her stressors are “I am having some high blood pressure, high anxiety, panic attacks, and I have a really stressful job and I am worried about my health issue.” She was prescribed by her PCP on Fluoxetine 10mg, a week ago. She denies side effects. She denies any medical complaints currently. She states PCP treating her hypertension. She reports feeling anxious, being unable to control worrying, trouble relaxing, becoming easily annoyed or irritable, feeling afraid that something awful might happen nearly every day; reports worrying about many things on most days; denies feeling restless. She reports trouble sleeping, decreased energy, change in appetite, difficulty concentrating, nearly every day; reports feelings of guilt on most days; reports feeling depressed, loss of interest on some days; denies psychomotor slowness, suicidal ideations. She denies distractibility, impulsivity, grandiosity, flight of ideas, activity increase, spending/sexual indiscretion, increased talkativeness. She reports 1 panic recently while admitted in the hospital, denies hallucinations. She reports sleeping 5-6 hours per night and reports nightmares. She reports not feeling rested upon awakening. She reports a poor appetite. She reports stopped energy drinks 2 weeks ago, reports stopped vaping 3 weeks ago, denies alcohol use, denies illicit drug use, denies narcotic use, denies steroid use. She reports that she is not seeing a counselor or therapist currently. She rates her mood at out of 10, with 10 being the best. Initially the history is gathered by a PMHNP Student, after verbal permission from the patient, then I reviewed the history, examined the patient in detail in the presence of the student (ARG).
GAD7:17
PHQ:16
Past Psychiatric History:
She states her only previous treatments were medications only (see previous psychiatric medications). When she was 16 years of age, she was diagnosed with depression and borderline personality disorder after two SI attempts. First, she overdosed on unknown medication and was administered activated charcoal, she then was admitted to a psychiatric inpatient faciliy. She states her second SI attempt was a combination of an overdose and vertical cutting her arm in an attempt to “open a vein”, she again was found by her mother and admitted to an inpatient psychiatric facility. Her third SI attempt was at the age of 20. She states she overdosed on heroin, and someone treated her “at home after being dead for three minutes”. She denies treatment at this time and stopped taking all psychiatric medications and stopped therapy and consultation with her psychiatrist. She states history of sexual trauma in childhood and during her teenage years but fails to elaborate.
Previous Psychiatric Medications: Lithium, states only took for a short period of time due to no insurance to get the lab work done regularly, felt some benefit. Seroquel made too tired, Lexapro, Abilify and Sertraline. Patient is unknown how long any of the medications were or dosing. She states she does not remember what works or doesn’t or when she took them.
Current Medications:
Medical:
Lisinopril 20mg PO daily
Fluticasone propionate 50mcg spray daily
Budesonide-formeterol 80-4.5mcg spray
Psychiatric:
Fluoxetine 10mg daily (started one week ago by PCP)
Substance use/Addictive behaviors:
She states during age 19-20 years she had impulsivity and used heroin with her first husband and states “just stopped taking”. She also participated in risky sexual behaviors. She states she just stopped using heroin and received no need for treatment. She then states her impulsivity switched to binge eating were she will go longer than 24 hours without eating to eating everything she can. She also admits to excessive shopping but denies legal issues from this impulsivity.
Family Psychiatric History:
Mother: undiagnosed, patient states “not normal”
Maternal grandmother: Bipolar
Aunt: Bipolar, inpatient psychiatric admissions
Father: PTSD
Half-siblings: unknown
Medical History:
Allergies: Prednisone (rash)
Surgeries: Cholecystectomy
Illnesses:
Asthma (childhood unresolved)
HTN, 4 months
Inflammation around the heart (unknown dx)
Past Illnesses: Denies
Lab Results: Recent admission to hospital, sending to office
Development/Psychosocial: 36-year-old female raised with her mother and father. She is the only child of her mother; her father has other children she does not know. She has been married twice. She is currently still married to her second husband but does not know were he is. She currently lives with her boyfriend in a house they just purchased. She denies ever being pregnant. She states she does not have a lot of friends and has trouble maintaining relationships. She states she can meet people easily and form bonds but is unwilling to put in the effort to maintain the friendships/relationships. She works for CPS as an assistant manager. She has no developmental delays. Denies religious affiliation and miliary service.
Assets/Stressors: She states assistant manager with CPS and works active cases. She states she they are short staff and she at times must cover multiple roles. Her health is also a concern with recent removal of her gallbladder and hypertension. Her boyfriend also got a DUI this week and unsure of were her second husband is.
ROS:
Anxiety
Generalized anxiety symptoms: Patient states she feels anxious due to increase stress at work. She denies sweating, palpitations or pain.
Panic disorder symptoms: Denies
Obsessive-compulsive symptoms: Denies
Posttraumatic stress disorder: Patient states she had nightmares about situations that occurred earlier in life but would not elaborate.
Social anxiety symptoms. Denies
Simple phobias: Denies
Borderline Personality Disorder:
Posttraumatic Stress Disorder: states history of sexual trauma in both childhood and teenage years.
Borderline Personality Disorder: stated history of three suicide attempts.
Objective:
MSE:
The patient is a Caucasian female who is alert and oriented to person, place, time and situation. She is appropriately dressed in attire and for the current weather She has adequate grooming and hygiene. She is cooperative with a good attitude, good eye contact, normal psychomotor activity. She shows no signs of agitation, tremors or involuntary movements. Her behavior and affect are appropriate for her age and situation. She is attentive to the interviewer and engages in the conversation. Her speech is of a normal rate, amplitude and prosody. She can comprehend questions and articulates her needs and ask pertinent questions to the topic. Her thought process is organized, logical and linear. There are no signs of thought blocking, rambling or repetition of words, sentences, ideas or topics. No abnormal thought content. Patient denies delusions, hallucinations, phobias, SI or HI. She does have thoughts of being better off unalive but with no active plan or thought to carry out any thoughts. She possesses full insight and good judgment with recent and remote memory intake.
Physical Exam: Differed due to tele-health visit. Last seen by PCP a week ago.
Laboratory Data: completed at hospital and PCP’s office. Not on file, patient to submit through portal.
Vital Signs: Weight 270lbs. Height 5’3.
Differential:
Narcissistic personality disorder: vulnerable self-esteem (history of abuse) with attempts at regulation through attention and approval seeking and grandiosity. This is shown through identity, self-direction, empathy and intimacy.
Post traumatic disorder and adjustment disorder: through her childhood and adolescent sexual abuse history. This used when other criteria not met. With adjustment disorder it general occurs within 3 months of onset of the stressor and does not present beyond 6 months.
Formulation:
Axis I- Borderline, Depression, Anxiety
Axis II- deferred
Axis III- Hypertension, Asthma
DSM Criteria of Diagnostic Formulation for Borderline Personality disorder:
1. Identity with marked or unstable self-image associated with excessive criticism.
2. Intimacy with unstable and conflicted close relationships, marked by mistrust, neediness and withdrawal.
1. Emotional liability with unstable experiences and mood changes.
2. Anxiousness- regarding nervousness and fearfulness toward her and her friend’s health and fears of dying.
3. Impulsivity with binge eating and shopping currently. Previously with sex and drug use.
4. Risk taking history of risky sexual situations that put herself and partners at risk.
Risk Assessment:
Currently the patient is at a moderate risk for harm. Previously patient was depressed with SI attempts. Patient states that she often has thoughts of it being better if she was unalive but actively denies thought, intent or plan regarding active suicidal thought. She does states that previous counseling has helped develop coping strategies with negative thinking that lead to active suicidal thought.
Recommendation and Plan with goals and rationales with Neurobiology:
Psychotherapy is the primary treatment for borderline personality disorder (BPD). The patient need therapy to focus and manage the unconscious processes, early childhood influence and internal conflicts that lead to impulsivity (sexual, drugs, binge eating and shopping) as well as social anxieties and difficulty with relationships (2 marriages and a boyfriend) (“Borderline Personality Disorder,” 2024).
Begin Lamictal 25mg daily for 2 weeks and then increase to 50mg. Patients that suffer from BPD generally have underlying mood disorders and can suffer from anxiety and depression. Lamictal is a mood stabilizer that has shown efficacy with BPD patients
Follow-up in 4 weeks to evaluate effectiveness of Lamictal and anxiety symptoms. Lamictal has shown in some studies as drastically reducing impulsivity (“Efficacy and Tolerability of Lamotrigine in Borderline Personality Disorder: A Systematic Review and Meta-Analysis,” 2020)
Goals: to reduce impulsive behaviors and reduce consequences. First, patient will start eating three meals a day to reduce binge-eating from fasting greater than 24hours. Second, patient will try and set amount of money to spend on personal wants to avoid excessive and unnecessary shopping/spending.
References
Borderline personality disorder. (2024). Annals of clinical psychiatry : official journal of the American Academy of Clinical Psychiatrists, 25(2).
Efficacy and tolerability of lamotrigine in borderline personality disorder: A systematic review and meta-analysis. (2020). Psychopharmacology bulletin, 50(4). https://europepmc.org/articles/PMC7511148?pdf=render
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