DENTIFICATION: Age: 40.

ETHNIC STATUS: Caucasian.

RELIGION: Jewish/Pagan.

CHIEF COMPLAINT: "My psychologist said I was just too unstable to do outpatient therapy; she
suggested your facility because I have so many medical issues."

ESTIMATED LENGTH OF STAY: 7-10 days.

HISTORY OF PRESENT ILLNESS: Patient is a married 40-year-old Caucasian female, who is here
voluntarily due to reports that she is having suicidal ideation. She is too tired to care. Has had a
migraine for the past 2 weeks. Only showering once a week. Her cat died abruptly 3 weeks ago.
She has been under a lot of stress and has numerous medical problems and is now on disability
due to an inability to work. She has been canceling appointments because she does not have the
energy to go. Had a new stressor, being told she had a breast lump; but did recently find out that
was benign. Also has a history of lung cancer. There is sometimes stress between she and her
husband due to her medical issues. She arrives to our facility prescribed Cymbalta, Wellbutrin,
Klonopin, p.r.n. Adderall for her psychiatric medication.

When the undersigned meets with the patient today, she presents as very friendly and is felt to
be an accurate historian. She shares a very lengthy mental health history, with numerous
comorbid medical issues. She said that she deals with fibromyalgia, numerous food allergies,
chronic migraines, excessive daytime sedation; and as mentioned above, she has had her current
migraine for 2 weeks. She is also very concerned about excessive weight gain over the past year.
She thinks that she has gained about 100 pounds. She says that she was trying to do outpatient
therapy; but was telling her psychologist how bad she felt and the psychologist said that she
needed to get things under control before they could proceed. She was hospitalized twice at a
facility in Illinois; but she felt like they were not addressing her medical issues, which she feels is
a big part of her problem.

She also feels that she is having a "flare of mononucleosis," which is also contributing to her
lethargy. She says that she has excessive daytime sedation, to the point she is forgetting to get
up to take her morning medications. She admits that she has barely taken her Wellbutrin in the
past month and had not even picked up the prescription. She said she is just too tired and does
not care. When she was on it in the past, it did help significantly; but she just cannot seem to
make herself take it. Her outpatient psychiatrist did recently reduce her Cymbalta, with a gradual
plan to take her off of it completely as she feels it is one of the medicines that contributed to her
weight gain. She says the suicidal thoughts are passive at best; but she has no quality of life and
is losing interest in things that she enjoys, such as taking care of her numerous pets and tutoring
in science. She said she is on disability and knows that she will never be able to get back to full-
time work, but she would like to be able to still have that in her life.

Today, she says her husband is supportive and she did not identify any issues in the relationship,
other than some sexual issues because of husband's inability to perform due to medications that
he is on. She said that they are both supportive with one another. She denies psychotic
symptoms. Says that she has symptoms consistent with cyclothymia, which is what they have
diagnosed her with in the past. It was noted during the course of the evaluation that she knows
mental health terminology, frequently using terms like "BPD" to describe her mother that she
thinks has borderline personality disorder. She feels that she has "aphasia" from some of her
migraines. She was referencing various neurotransmitters. She does seem very motivated for
care and says that she wants to be better. The one thing that she wanted us to know is that
sometimes she presents better than she feels because she has learned to put on a happy face
and get through the day; so she sometimes looks better than she really is.

PAST PSYCHIATRIC HISTORY: Patient alludes to extensive past psychiatric history, with previous
hospitalizations. She is currently in outpatient treatment at --------------. Has not seen her
psychiatrist since December and mentions that insurance has been trying to move offices and
various providers. Her only suicide gesture was holding a knife to her wrist, but she said she has
had no actual attempts. She has smoked marijuana in the past, but gave it up completely once
diagnosed with lung cancer. She said she cannot use alcohol because she is very sensitive to it
and it just makes her more tired. Previous medication trials have included Effexor, Paxil, Celexa,
Lexapro and Lamictal. She says she is allergic to Lamictal and gets hives from it, but it actually
worked well for her and helped her to lose weight. She has been on Topamax for her migraines,
but they made her even more lethargic and like a "zombie."

PERSONAL HISTORY: She was born in ---------------------s. Moved for a period of time to California
and Texas. She has a graduate degree. Was a science teacher. Currently on disability and tutoring
part-time. She was married to a man who was a makeup artist. Cheated on him with her current
husband. She has no children and says she cannot have children because she has endometriosis.
She is very involved in caring for animals, fosters, rescue animals, and says she gets a lot of joy
from this. She enjoys nature. She considers herself to be Jewish and Pagan. She believes that she
was sexually mistreated at the age of 3, but says it is a "memory that my brain will not let me
have" and has a vague recollection of being taken off of her bike into the woods and that
something bad happened. She said she started masturbating excessively after that and has a lot
of issues related to this incident.

FAMILY HISTORY: There is a lot of mental health issues on maternal side of family. Some aunts
have depression. Mother likely had borderline personality disorder. There is alcoholism on
mother's side of the family. No suicide attempts.

MEDICAL HISTORY: Patient has fibromyalgia, migraines, endometriosis, gastroesophageal reflux,

history of lung cancer.

SURGICAL HISTORY: Significant for lower left lobectomy, two endometriosis surgeries, ACL
replacement and appendectomy.

ALLERGIES: CECLOR, DOXYCYCLINE, LAMICTAL, and BEES.

MEDICATIONS AT TIME OF ADMISSION:

1. Omeprazole 40 mg daily, gastric reflux.

2. Cymbalta 30 mg at bedtime, depression.

3. Wellbutrin XL 150 mg daily, antidepressant.

4. Klonopin 1 mg at bedtime, anxiety.

5. Dicyclomine 10 mg before meals for irritable bowel.

6. Rizatriptan 10 mg as needed for migraines.

7. Amphetamine salts 15 mg p.r.n. attention deficit (patient takes before tutoring or when she
needs to focus or concentrate).

8. Breo Ellipta, 1 puff daily, asthma.

9. Birth control daily.

10. Albuterol 90 mcg, 2 puffs every 2 hours as needed for asthma.

11. Probiotic 3 mg daily, bowel health.

12. Fioricet, 1-2 tabs q.6 hours as needed for migraine.

13. Flexeril 5 mg bedtime, muscle spasms.

14. Metoclopramide 10 mg 3 times daily as needed for stomach issues.

15. Vitamin D2, weekly supplement.

MENTAL STATUS EXAMINATION:

APPEARANCE: Patient is sitting calmly on her bed. Appears stated age. Grooming and hygiene
within the normal range. She is noted to be overweight.

GENERAL BEHAVIOR: Shows patient was very friendly, pleasant, well spoken. No abnormal
movements.

ATTITUDE TOWARD EXAMINER: Cooperative.

STATE OF CONSCIOUSNESS: Alert.

ATTENTION AND CONCENTRATION: Within the normal range. She is able to spell world forward
and backward without any difficulty.

ORIENTATION: She is oriented in all 4 spheres.

PSYCHOMOTOR ACTIVITY: Normal.

MOOD: Described as very depressed.

AFFECT: Noncongruent; but as patient stated, she learns to put on a happy face and presents
much better than she feels.

SPEECH: Fluent, spontaneous, with a normal rate and tone.

FORM OF THOUGHT: Logical, coherent and goal-directed.

CONTENT OF THOUGHT: Without any current active suicidal ideation. She says she just does not
care. Has a very poor quality of life. No delusions or obsessions.

PERCEPTION: No auditory or visual hallucinations.

MEMORY: Intact in all areas. She was able to remember very detailed history of past, all
medications, dates of hospitalizations, etcetera.

INSIGHT: Intact. She does accept the need for treatment. Is here voluntarily. Appears motivated.

INTELLECTUAL FUNCTIONING: Average to above average. She was able to abstract proverbs
appropriately. Has a graduate degree in science.

ASSETS: Patient is very motivated for treatment. Has supportive husband, religious faith, love of
nature.

BARRIERS AND LIMITATIONS: Numerous medical comorbidities. Some noncompliance with

medication.

DIAGNOSTIC IMPRESSION:

Axis I:

1. Cyclothymia.

2. Attention-deficit hyperactivity disorder.

3. Rule out a somatic symptom disorder.

Axis II: Deferred.

Axis III:

1. Fibromyalgia.

2. Migraines.

3. Gastric reflux.

4. Asthma.

5. Irritable bowel syndrome.

6. History of lung cancer.

7. Gastric reflux.

Axis IV: Severe.

Axis V: A GAF of 20.

PLAN: Psychiatry Medication Management: Will increase Wellbutrin to 300 mg daily, discontinue
the Adderall. We will trial Provigil 100 mg daily for excessive daytime sedation and treatment-
resistant depression. Discussed ongoing taper to discontinue Cymbalta. Patient asks if we can
wait until her migraine clears before proceeding with this plan. We will request records from
Linden Oaks, both inpatient and outpatient records for continuity of care. We will continue the
other psychotropic medications as prescribed.

Psychology will evaluate the patient and perform appropriate testing. She will be placed in
individual groups and therapy as warranted. Internal Medicine will follow the above medical
conditions. Activity will involve patient in social milieu. Social Work will work on discharge
planning, gathering psychosocial history and planning family therapy meeting.

RATIONALE FOR INPATIENT STAY: Patient is in need of hospital level of care due to meeting
criteria as gravely disabled and dangerousness to self.