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Mrs. R., a 67-year-old retired teacher, has struggled with recurrent major depressive episodes throughout her life beginning in her late 20s. It was not until 2 months ago that she started experiencing some manic symptoms. She presents tonight to the emergency room with her husband, who was becoming increasingly concerned that Mrs. R. was “not acting like herself.” At first, her husband noticed some restlessness; Mrs. R. seemed to have a hard time relaxing. It then progressed to an inability to fall asleep and stay asleep. For the past 6 weeks, she has been averaging 3–4 hours of sleep per night, compared to her usual of 8–9 hours. In the past month, she has also taken on some new projects within the home. She decided to renovate their kitchen, their master bathroom, and redo their backyard deck all within the same week. She has contacted numerous contractors and purchased various home improvement magazines and books but has not been able to progress further into the planning stages as she becomes easily distracted by other things. When her husband asks her to slow down and perhaps just focus one project, she becomes irritated and yells that he never lets her do anything that she wants. He feels that she is much more short tempered in the past month. In the past week or so, she has spent most of the day in church, praying. Although Mrs. R. is a Christian, she typically goes to church only once or twice a month. She indicated to Mr. R. that she has been going more often in the past week because she needs to repent her past sins. She has a “feeling” that if she does not repent her sins, then something horrible would befall her family. On mental status examination, Mrs. R. appeared well groomed but dressed a youthful, “trendy” style. She was annoyed at having to come to the hospital as she felt there was nothing wrong with her. Her thought process was tangential, but she was able to be redirected with some effort. Initially, Mrs. R. scoffed at the question of suicide but later made the comment that if she had to stay in the hospital any longer, hospital staff might as well “kill me now” as she cannot stand to be in a “prison.” Throughout the assessment, she was pacing back and forth in the interview room. Medically, Mrs. R. is relatively stable. While she does have a history of hypertension and dyslipidemia, both these conditions are well controlled with medications. Her hypothyroidism has also been stable over the past years with her laboratory results being monitored regularly by her primary care physician. She had a previous fracture of her right tibia and fibula about 10 years ago from a skiing accident that did require surgical intervention. She has struggled with chronic pain in her lower right leg as a result. Her medications are ramipril 5 mg qam, atorvastatin 40 mg qhs, escitalopram 15 mg qhs, lorazepam 2 mg qhs, pantoprazole 40 mg ac meals, and levothyroxine 75 mcg qam. Her vital signs on initial presentation showed a blood pressure of 132/76 mm Hg, heart rate of 103 BPM, and O2 saturation at 98%. The emergency physician ordered basic laboratory investigations including complete blood count (CBC), electrolytes, creatinine, estimated glomerular filtration rate (eGFR), total bilirubin, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, and thyroid-stimulating hormone, which were all within normal limits.