A 31 year old female presents to your office with her husband.

A 31 year old female presents to your office with her husband. He is concerned about her because he indicates that her behavior has recently changed. He reports that she has not slept for most of the past week and she has been sending text messages to friends and family at all hours of the night. He notes that a few weeks ago, she went out and spent over $4,000 on dresses, shoes and handbags (noting that she has a closet full of these things already). He notes that she has also been out driving under the influence of alcohol but thankfully has not hurt herself or anyone else. The husband reports that she has also missed work 6-7 times this month. Patient denies depressed mood and reports “everything is fantastic” as she laughs audibly and inappropriately.

Physical Exam:

Vital Signs Stable

Gen: patient is dressed provocatively, talking very fast and is moving from subject to subject without connecting topic areas. Conversation is difficult to follow and she is a poor historian.

Physical exam is otherwise normal.

PMH: Hypothyroidism

PSH:None

Family Hx: Father- Hypertension and Diabetes; Mother: Hypothyroidism,  Breast Cancer, anxiety; Sister: mental health disorder but patient is unsure of exact diagnosis

Medications: Levothyroxine 112mcg

Allergies: Sulfa

Questions:

1. What is the most likely diagnosis with rationale based on this patient’s presentation?

2. What are 3 different diagnosis and how to do you support those differentials? How would you rule them in or out?

3. What pharmacoligical treatment options are available for this patient (list at least 2 and name the medication, dosing and frequency)?

4. What non-pharmacoligical treatment options are available for this patient (list at least 2)?

5. What type of patient education would you provide this patient and her husband?