Vibe Rounds — Case Export
Specialty: Psychiatry · Setting: outpatient clinic · Difficulty: intermediate · Status: ongoing · Turns: 3
Exported 2026-07-24T14:02:50.385Z
Case Chat Log
Case
A 32-year-old software engineer, Marcus, presents to the outpatient psychiatry clinic accompanied by his wife. She made the appointment because she is deeply concerned about his behavior over the past three weeks: he has been sleeping only 2 hours per night, talking continuously at a rapid pace, and recently spent $15,000 of their savings on an unvetted cryptocurrency venture. Marcus smiles widely, leans forward in his chair, and says, 'Doc, I've never felt better in my life! My mind is operating at 200% capacity and I don't need sleep anymore.'
You
any substance abuse recently or in past?
Case
Marcus chuckles and shakes his head, 'Substances? Doc, I'm high on life and pure ambition! I don't need drugs.' His wife adds, 'He doesn't use illicit drugs or abuse prescription medications. He drinks one cup of coffee in the morning and might have a beer on weekends, but that's it. I've known him for eight years and he's never had a problem with drugs or alcohol.'
Peer
Good job getting collateral on his substance history. To help rule out medical causes of mania like thyroid dysfunction or occult substance use, consider ordering screening labs like a TSH, CMP, CBC, and a urine drug screen. You might also want to ask whether he's ever had mood symptoms like this—or periods of deep depression—in the past.
You
order screening labs like a TSH, CMP, CBC, and a urine drug screen.ever had mood symptoms like this—or periods of deep depression—in the past?
Case
The nurse brings back the lab results: TSH, CMP, CBC, and UDS are all completely within normal limits. When asked about past mood episodes, his wife reveals, 'Four years ago in grad school, he had a terrible episode where he couldn't get out of bed for almost two months, cried constantly, and felt completely hopeless. His PCP put him on sertraline for a bit. Two years ago he had a brief period where he worked around the clock on a project with little sleep, but it wasn't as extreme as this.' Marcus waves his hand dismissively and says, 'That depression was just grad school stress! I'm completely past that now.'
SOAP Note
S — SubjectivePatient denies past psychiatric history, but collateral from wife reveals a prior 2-month Major Depressive Episode 4 years ago treated briefly with sertraline, and a past hypomanic period 2 years ago.
O — ObjectiveLabs (CBC, CMP, TSH, UDS) all unrevealing/normal. Mental status remains notable for euphoric, grandiosity, pressuring speech, decreased sleep, and lack of insight.
A — Assessment32-year-old male with full criteria for acute manic episode (decreased sleep, flight of ideas, pressuring speech, risky spending) and history of prior Major Depressive Episode. Normal thyroid function and negative UDS rule out common organic/substance etiologies. Diagnosis strongly points to Bipolar I Disorder, current episode manic.
P — PlanDiscuss diagnosis with patient and wife, evaluate for safety/need for hospitalization vs outpatient initiation of mood stabilizer/antipsychotic, assess for psychotic features.
Differential (ranked)
- Bipolar I Disorder, current episode manic - confirmed by presence of full manic episode + history of major depressive episode; organic causes ruled out
- Bipolar II Disorder - ruled out because current episode meets full criteria for mania (severe functional impairment, severe financial risk)
- Schizoaffective Disorder, Bipolar Type - less likely unless prominent psychotic features persist in the absence of mood symptoms
Clinical Pearls
- Decreased *need* for sleep (feeling energized after 1-2 hours) is a core diagnostic hallmark of mania/hypomania, distinguishing it from insomnia where patients feel fatigued.
- Obtaining collateral history from family members or close contacts is essential in psychiatric evaluations, particularly in mania where patient insight is frequently impaired.
- Unmasked mania or rapid cycling can be precipitated by SSRI monotherapy (e.g., sertraline) in patients with underlying undisclosed or unrecognized bipolar illness.
Vitals
Labs
| Test | Value | Flag |
|---|
| TSH | 1.85 mIU/L | normal |
| CMP | Na 140, K 4.2, Cl 101, HCO3 24, BUN 14, Cr 0.9, AST 22, ALT 25, Glucose 92 | normal |
| CBC | WBC 6.8, Hgb 15.2, Hct 45%, Plt 240 | normal |
| Urine Drug Screen | Negative for amphetamines, cocaine, THC, opiates, PCP, benzos, barbiturates | normal |