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60 yo Caucasian female

Case Study 3A
Identifying Information: 60 yo Caucasian female
Reason for encounter: Follow-up after ED visit in which she reported rape by husband and other men which she did not actually witness, and vaginal pain. Also needs psychiatric medication management.
Hx of Present Illness: Her PCP referred her for psychiatric care at her primary care clinic. The psychiatric provider was recommended to the patient by her insurance provider. She said she needs a prescriber for her psych meds and also wants someone to talk to about her trauma history. She is happy with her current psych meds and doesn’t see any reason to change them.
At her initial visit with new psych provider, she reported the following information. She believed her mental health issues started at age 12 when she suffered from trauma. She self-diagnosed a mental health problem starting at that age that she now believes is bipolar disorder and PTSD. She has a history of persistent anxiety that has been treated for years. She described her anxiety as somewhat worse due to concerns about her health. She reported being anxious and restless much of the time, every day, and reported doing a lot of rearranging of various articles around her home. She was worried about her health and finances. She was having nightmares and intrusive memories about her past trauma and reported that there are certain behaviors/activities that she avoids due to the trauma. She reported no appetite with weight loss of 25# over the past year. She reported a great deal of difficulty sleeping without her meds. She reported having panic attacks with upset stomach, nausea, anxiety, irritability, restlessness that lasted 20 – 30” and was relieved by folding laundry. She described her history of mania as spending money on her daughter and groceries when she was angry, and spending too much money with her husband. She also reported feeling restless, hearing music, and feeling like she was floating above her bed. The only treatment she had tried was psych meds. She denied obsessions or compulsions, but her record showed that she had been diagnosed by a medical provider as having trichotillomania with concomitant sores over her body that were infected due to picking at them.
When asked about the recent ED visit and the related concerns, she reported that she had experienced vaginal pain and being raped, first by her husband, then by unknown people coming into her home while she was sleeping, and her husband was out of town. She says she has never actually seen or felt her husband raping her but is sure that he has done this. She also says her husband puts tiny needles in her ears, eyes, nose and mouth, and makes them sting. She has not seen the needles, nor has she seen him do this. She reported being sad and depressed and more anxious lately. She did not seem afraid or agitated during this discussion. The report provided by ED staff indicated that they had called her husband (he was out of town); he reported that she has been delusional and “schizophrenic” for about a month.
Current Psych Treatment: none
Past Psych Treatment: saw a local PMHNP for 5 years, followed by another PMHNP for 2 months, prior to coming to this clinic. Had seen at least one psychiatrist in the 2000s.
Previous psych meds: said her current meds were perfect and didn’t want to change; had been on lorazepam previously while hospitalized, effectiveness not reported. Had been on other meds but did not identify them. Records requested.
Previous psych hospitalizations: 1987 x 1 week at Providence, for insomnia, reported by patient. (Care Everywhere through EPIC record revealed a psych hospitalization in 2003 for depression and insomnia)
Previous suicide attempts: no
Previous homicide/violence: no
Previous psych diagnoses/problems: yes, identifies PTSD, bipolar disorder (she doesn’t know if type I or II), anxiety, depression
Medical HX: arrhythmia, MI, syncope and collapse, staph infection, trichotillomania
Allergies: Bactrim
VSs and Lab:
BP: 98/72; T 97.6; P 86; weight 103#; height 5’5”
Labs: none recently available, had been seeing a PCP at outside clinic, recently started at current clinic
Asenapine 10 mg SL HS
Gabapentin 300 mg po BID
Metropolol 25 mg BID
Chlordiazepoxide 25 mg TID
Trazodone 150 mg HS
Suvorexant 20 mg po HS
Social hx: married, with 2 children. Is on disability. Retired from Fred Meyer after 30+ years of employment.
Substance Use Hx; no ETOH use. Distant past use of drugs. Smokes 0.5 ppd.
Family psych Hx: reports no suicides, no known mental health disorders
Trauma hx: was raped and beaten at age 12; was grounded by her parents for having left the house (after which she was assaulted); when her horses were stolen, she was told it was punishment for having left the house.
Appearance: well-groomed, wearing a mask over her mouth, very thin, multiple facial and neck scabs
Constitutional: thin, alert, no acute distress
MSK/motor: WNL, no abnormal motor movements
Attitude/manner: cooperative, open and engaged, pleasant
Speech: normal rate, volume, tone
Mood & affect: anxious, full range of affect, mood congruent affect
Thought processes: linear, goal directed
Associations: intact
Thought content: intact and appropriate with no evidence of delusions, paranoia, or hallucinations
Suicidal ideation: denies Homicidal/violence ideation: none
Perceptions: WNL
Memory: grossly intact
Attention/concentration: appropriate eye contact
Language: English; vocabulary: average; appropriate use: yes
Fund of knowledge: intact
Orientation: x4
Judgment: fair
Insight: fair

PHQ-9 = 19 (compared to score of 8 one month prior)
GAD-7 = 20