report

1. 1
Mental Health Consultation
Patient Name: hypomania Facility: XXXX
Date: 9- 9-13
There appears to be some urgency about receiving these findings and recommendations.
Therefore, I will limit this report primarily to those categories. History and background
information can be found elsewhere in this chart.
Reasonfor Referral: XX-year-old, white, xxxxx, female… I was asked to evaluate her
because “she was pleasant until recently, now she is all over the place…high one minute and the
next minute she accuses you of beating her up…almost delusional…complains about everything”
She was admitted from XXXX on 7-9-13 where she had been treated for a left knee fracture,
mild pneumonia and a UTI.
Current Medications: Paxil 30mg qd, Prilosec, Lipitor, Hydrocodone-APAP 7.5/325 q 4hr prn,
Klonopin 0.5mg bid, Depakote 250mg bid, Oxybutynin, Tramadol 100mg bid.
Medical History: GERD, Hyperlipidemia, Coronary Artery Disease, Anemia, Obesity, Bipolar
Disorder, COPD, CRI, Osteoarthritis, Anxiety State, Migraine, Sick Sinus Syndrome with
Pacemaker, S/P Greenfield filter placement & Bilateral knee replacements, questionable history
of Darvocet abuse.
Mental Status Exam: She was on the phone. I had to ask her to end a one hour phone call to
her son. She looked up at me from her W/C and said, “Am I crazy?” She was alert and restless.
Her speech was coherent, spontaneous, slightly pressured and a bit circumstantial and tangential.
Her affect was labile and her mood alternated between fleeting tears, anger and frustration “I
want to get out of here” and similes. She complained of depression and anxiety, as well as,
insomnia and loss of appitite. There were no obvious delusions or hallucinations. She was
oriented to person, place and time. Her insight and judgment were impaired. She was mildly
paranoid “The NH people said they would take care of my money, but.” “In the past I went off
the deep end…thought people were after me…not now though” Said she has been anxious since
the death of her husband “He took care of everything for me”
Findings and Recommendations: Bipolar disorder is a much over used and often incorrectly
applied diagnosis and we have no history here which supports that diagnosis. However, clinically
she is exhibiting some signs of hypomania including those highlighted below:
a) Persistent, elevated, expansive, irritable mood and labile affect.
b) Inflated self-esteem and grandiosity.
c) Flight of ideas plus the subjective experience of racing thoughts (i.e. “My mind works so
fast, I can hardly keep up with it”). Pressured speech
d) Distractibility and inattention.
e) Absence of insight and grossly impaired judgment.
f) Well-developed paranoid trend in thinking.
g) Aggressiveness and verbal abuse.

2. 2
This diagnosis cannot be definitively ruled in or ruled out without an accurate psychiatric
history. In the mean time we can try to back into the diagnosis by treating this empirically as if it
was Bipolar II hypomanic then observe for the response. Therefore would:
1. Increase Depakote to 500mg bid and obtain a level at trough in 3 days. Titrate up if no
response and the level is below 85 (>100 = toxic). Titrate down if there is excessive
sedation.
2. To treat acute signs and symptoms of hypomania start Zyprexa 2.5mg bid.
3. Obtain an accurate psychiatric history from family and primary care doctor...onset of
illness… signs and symptoms…past treatment…who made the Bipolar diagnosis?
Use of Paxil carries a special risk for hyponatremia and impairment of cognitive and motor
functions in the elderly and therefore is rarely used in this population now.
4. Therefore, would switch her to Lexapro by reducing Paxil to 10mg qd and starting
Lexapro 10mg qd times two weeks then DC Paxil and increase Lexapro to 20mg qd.
Klonopin is intermediate acting and can have a cumulative effect causing confusion even in the
elderly who do not suffer from renal insufficiency. She does have CRI increasing the risk of this
problem.
5. Would switch her to a shorter acting benzodiazepine such as Ativan.
An alternative diagnosis is histrionic personality disorder which is characterized by: a)
difficulty achieving intimacy in relationships b) use of physical symptoms as an appeal for help
c) symptoms which are dramatically described but vague d) a tendency to alienate others with
demands for attention e) frustration in situations that involve delayed gratification f) actions
which are directed at obtaining immediate satisfaction g) a tendency to become angry,
demanding and coercive when needs are not met h) fleeting, shallow emotions i) a pattern of
manipulating others into gratifying needs o) melodramatic theatricality and the exaggerated
expression of emotion to influence others. This is a strong possibility.
Less likely possibilities include: a very mild dementia and/or residual delirium.
6. I will offer more after we clarify the diagnostic issues.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist