Week 4: Assessing, Diagnosing, and Treating Adults With Mood Disorders
College of Nursing-PMHNP, Walden University
Dr. Vardah Seraphin
NRNP-6665C-1: PMHNP Care Across the Lifespan I
Subjective:
CC (chief complaint): “I have a history of taking medications and then stopping them. I don’t think I need them. I really feel like the medication squashes who I am”
HPI: P.P is a 25 year old female who presented to the clinic for mental health assessment. She mentioned that she was hospitalized about four times due to mental health problems. One was when she was a teenager, she was admitted to the hospital after she went four or five days without sleeping. She didn’t have much sleep that week. And police took her to the hospital because she was dancing around in her nightgown in a field with her guitar. She believe she may have been hearing things at that time and was started on some medication. She was also admitted to hospital back in 2017 when she overdose herself with Benadryl. Also, she didn’t remember much on once of the hospitalization, but her mother told her that During the assessmnent, she was asked about her depression, she stated that sometimes she miss her job due her depression. For Mania: She mentioned that’s about 4 to 5 times in a year, she will have lots of energy working on her writing, painting, and music. According to her, she stopped taking her medication because she feel squashed and don’t have a lots of energy to do things. She can go like four or five days with very little sleep and usually get a lots of things done. At the end, she will feel like not getting out of bed due to no energy, no motivation to do anything, and just can’t feel any interest in her creativity. She feels worthless because is like her creativity was slipping away. The episode lasts about a week. Psychosis: She mentioned that about 2 month ago, whenever she don’t get enough sleep, she hear voices telling her how great and wonderfully talented she is. Denies recent auditory hallucination. Appetite: She usually don’t eat whenever she is creative, but eats everything at sight when she is at crashing and resting mood. Sleep: She denies any nightmales. She sleeps about 5 to 6 hours in a 24 hour period during her creative time, but sleeps about 12 or 16 hours a day on her creative times. Anxiety: She denies any anxiety or panic symptoms.
Substance Current Use: She smokes one pack of cigarrete per day. She denies current alcohol use, but the last time was when she was 19. No illegal drug use. She had history of marijuana use once, but it made her paranoid.
Family Psychiatric/Substance Use History: Father had illicit drug abuse, mother has bipolar, and brother has schizophrenia. Her mother had a history of suicidal attempt.
Past psychiatric history: Bipolar, Depression, anxiety, and suicidal attempt.
Past psychiatric medications: Zoloft (Made her feel high), Risperadone (Made her feel mind racing, and weight gain), Seroquel( Made her gain weight), Klonopin ( made her slow down). Other medication that started with L, seems to be healping her, “but it squashed me in creativity”.
Medical History: Hypothyroidism, polycystic ovaries.
• Current Medications: Birth control medication, unknown medication for Hypothyroidism.
• Allergies: NKA
• Reproductive Hx: Her LMP was 11/2020, She is sexually active and currently on a birth control. She has a boyfriend.
Psychosocial History: P.P was raised by his mother and older brother. Her father is currently in jail and she have not heard or seen him for the past 8 to 10 years. She is currently in vo-tech school for cosmetology. She is not married or have any children, but she currently stays with her boyfriend and sometimes lives with her mother whenever her boyfriend gets mad at her for sleeping around, which creats some issues in her relationship with her boyfriend. She works part time at her aunt’s bookstore, and sometimes, she doesn’t make it to work when she feels more depressed. She was emotionally abused by her father. She doesn’t have any legal issues. She stated that finding new people to explore sex with helps keep her moods high. She like to write and paint for fun.
ROS:
• GENERAL: Negative for weekness, chills, diaphoresis and fever
• HEENT: No head trauma, Eyes: Negative for discharges, pain or vitual disturbance. Ear:Negative ear pain. Nose: No nosebleed, sinus, or rhinorrhea. Throat: No sore throat, or throuble swallowing
• SKIN: Negative skin tear or rashes
• CARDIOVASCULAR: No chest pain or edema
• RESPIRATORY: Negative for cough, SOB, or chest tightness.
• GASTROINTESTINAL: Negative for abdominal pain, constipation, diarrhea, and N/V
• GENITOURINARY: Negative for flank pain, dysuria, hematuria, or frequency
• NEUROLOGICAL: Negative for dizziness, syncope, weekness, or seizure.
• MUSCULOSKELETAL: Negative for backpain, and myalgias
• HEMATOLOGIC: Negative for anemia or bleeding.
• LYMPHATICS: Negative enlarged node reported.
• ENDOCRINOLOGIC: Negative for cold intolerance, heat intolerance, polyuria and polydipsia.
• PSYCHIATRIC: Reports depression, lots of energy during maniac episode.
Objective:-
Diagnostic results:
Urine drug and alcohol screen negative.
CBC within normal ranges
CMP within normal ranges.
Lipid panel within normal ranges.
Prolactin Level 8
TSH 6.3 (H)
Vitals: Temp 98.2 Pulse 90 Respiration 18 B/P 138/88
Assessment:
Mental Status Examination: : For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Diagnostic Impression:
Differential diagnoses
Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Reflections:
Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Case Formulation and Treatment Plan
What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
References
provides at least three current, evidence-based resources from the literature to support the assessment and diagnosis of the patient in the assigned case study. The resources reflect the latest clinical guidelines and provide strong justification for decision making.
Week 4: Assessing, Diagnosing, and Treating Adults With Mood Disorders
College of Nursing-PMHNP, Walden University
Dr. Vardah Seraphin
NRNP-6665C-1: PMHNP Care Across the Lifespan I
September 25th 2022
Subjective:
CC (chief complaint): “I have a history of taking medications and then stopping them. I don’t think I need them. I really feel like the medication squashes who I am”
HPI: P.P is a 25 year old female who presented to the clinic for mental health assessment. She mentioned that she was hospitalized about four times due to mental health problems. One was when she was a teenager, she was admitted to the hospital after she went four or five days without sleeping. She didn’t have much sleep that week. And police took her to the hospital because she was dancing around in her nightgown in a field with her guitar. She believe she may have been hearing things at that time and was started on some medication. She was also admitted to hospital back in 2017 when she overdose herself with Benadryl. Also, she didn’t remember much on once of the hospitalization, but her mother told her that During the assessmnent, she was asked about her depression, she stated that sometimes she miss her job due her depression. For Mania: She mentioned that’s about 4 to 5 times in a year, she will have lots of energy working on her writing, painting, and music. According to her, she stopped taking her medication because she feel squashed and don’t have a lots of energy to do things. She can go like four or five days with very little sleep and usually get a lots of things done. At the end, she will feel like not getting out of bed due to no energy, no motivation to do anything, and just can’t feel any interest in her creativity. She feels worthless because is like her creativity was slipping away. The episode lasts about a week. Psychosis: She mentioned that about 2 month ago, whenever she don’t get enough sleep, she hear voices telling her how great and wonderfully talented she is. Denies recent auditory hallucination. Appetite: She usually don’t eat whenever she is creative, but eats everything at sight when she is at crashing and resting mood. Sleep: She denies any nightmales. She sleeps about 5 to 6 hours in a 24 hour period during her creative time, but sleeps about 12 or 16 hours a day on her creative times. Anxiety: She denies any anxiety or panic symptoms.
Substance Current Use: She smokes one pack of cigarrete per day. She denies current alcohol use, but the last time was when she was 19. No illegal drug use. She had history of marijuana use once, but it made her paranoid.
Family Psychiatric/Substance Use History: Father had illicit drug abuse, mother has bipolar, and brother has schizophrenia. Her mother had a history of suicidal attempt.
Past psychiatric history: Bipolar, Depression, anxiety, and suicidal attempt.
Past psychiatric medications: Zoloft (Made her feel high), Risperadone (Made her feel mind racing, and weight gain), Seroquel( Made her gain weight), Klonopin ( made her slow down). Other medication that started with L, seems to be healping her, “but it squashed me in creativity”.
Medical History: Hypothyroidism, polycystic ovaries.
2
- Current Medications: Birth control medication, unknown medication for Hypothyroidism.
- Allergies: NKA
- Reproductive Hx: Her LMP was 11/2020, She is sexually active and currently on a birth control. She has a boyfriend.
Psychosocial History: P.P was raised by his mother and older brother. Her father is currently in jail and she have not heard or seen him for the past 8 to 10 years. She is currently in vo-tech school for cosmetology. She is not married or have any children, but she currently stays with her boyfriend and sometimes lives with her mother whenever her boyfriend gets mad at her for sleeping around, which creats some issues in her relationship with her boyfriend. She works part time at her aunt’s bookstore, and sometimes, she doesn’t make it to work when she feels more depressed. She was emotionally abused by her father. She doesn’t have any legal issues. She stated that finding new people to explore sex with helps keep her moods high. She like to write and paint for fun.
ROS:
- GENERAL: Negative for weekness, chills, diaphoresis and fever
- HEENT: No head trauma, Eyes: Negative for discharges, pain or vitual disturbance. Ear:Negative ear pain. Nose: No nosebleed, sinus, or rhinorrhea. Throat: No sore throat, or throuble swallowing
- SKIN: Negative skin tear or rashes
- CARDIOVASCULAR: No chest pain or edema
- RESPIRATORY: Negative for cough, SOB, or chest tightness.
- GASTROINTESTINAL: Negative for abdominal pain, constipation, diarrhea, and N/V
- GENITOURINARY: Negative for flank pain, dysuria, hematuria, or frequency
- NEUROLOGICAL: Negative for dizziness, syncope, weekness, or seizure.
- MUSCULOSKELETAL: Negative for backpain, and myalgias
- HEMATOLOGIC: Negative for anemia or bleeding.
- LYMPHATICS: Negative enlarged node reported.
- ENDOCRINOLOGIC: Negative for cold intolerance, heat intolerance, polyuria and polydipsia.
- PSYCHIATRIC: Reports depression, lots of energy during maniac episode.
Objective:-
Diagnostic results:
Urine drug and alcohol screen negative.
CBC within normal ranges
CMP within normal ranges.
Lipid panel within normal ranges.
Prolactin Level 8
TSH 6.3 (H)
Vitals: Temp 98.2 Pulse 90 Respiration 18 B/P 138/88
Assessment:
Mental Status Examination:
The patient is a 25-year-old female who has reported to the clinic complaining of medication non-adherence. She admits that she experiences depression quite often and sometimes misses her job due to depressive symptoms. She ocassionally experiences manic episodes during which she reports to have lots of energy. The patient was alert and oriented to place, time, and person. She is appropriately dressed for the weather. She is attentive and aswers the questions asked. She denies recent auditory hallucination. She denies any panic or anxiety symptoms.
Diagnostic Impression:
Differential diagnoses
- Cyclothymic disorder (primary diagnosis)
- ICD-10 code: F34.0-Cyclothymic disorder
- Bipolar II disorder with rapid cycling
- ICD-10 code: F31.81- Bipolar II disorder, most recent episode rapid cycling
- Bipolar I disorder with rapid cycling
o ICD-10 code: F31.9- Bipolar disorder, depressed episode with rapid cycling
Rationale
Cyclothymic Disorder (Primary Diagnosis)
The primary diagnosis for the client based on her symptoms is cyclothymic disorder. The patient’s symptoms match both DSM-5-TR and DSM-5 criteria for cyclothymic disorder (American Psychiatric Association, 2013; American Psychiatric Association, 2022). The critical thinking process that was applied in selecting cyclothymic disorder as the primary diagnosis entails the evaluation of the patient’s symptoms and comparing them with the DSM-5-TR and DSM-5 diagnostic criteria for the disease. The specific patient’s symptoms that match the diagnostic criteria for cyclothymic disorder include; hypomania and depression symptoms that have persisted for more than 2 years, symptoms causing problems in one or more areas of life, and depressive and manic symptoms which are not enough to cause bipolar disorder ir major depressive disorder.
Bipolar II Disorder with Rapid Cycling
Bipolar II disorder is another possible condition for the patient’s symptoms. As outlined in the DSM-5-TR and DSM-5 manuals, the criteria for bipolar II disorder that confirm the presence of disease include fluctuating depressed mood and hypomanic symptoms. The symptoms cannot be associated with other mental conditions (American Psychaitric Association, 2013; American Psychiatric Association, 2022). In addition to these symptoms, the patient experiences 4 to 5 episodes of mania in a year thus prompting the classification of her bipolar disorder as ‘rapid cycling’ (Kupka et al., 2022). Bipolar II disorder with rapid cycling has not been considered at the patient’s primary diagnosis because the patient’s symptoms are not causing significant impairment in function.
Bipolar I Disorder with Rapid Cycling
The patients’s symptoms can be mistaken to be those of bipolar I disorder with rapid cycling. The reason is that they adequately align with the DSM-5-TR and DSM-5 diagnostic criteria for bipolar I disorder. The symptoms that align with those of bipolar I disorder include; the presence of both depressive and massive disorders. Manic episodes are characterized by increased energy. Both manic and depressive symptoms cannot be associated with any other mental illnesses (American Psychiatric Association, 2013; American Psychiatric Association, 2022). In addition to these symptoms, the patient experiences 4 to 5 episodes of mania in a year thus prompting the classification of her bipolar disorder as ‘rapid cycling’ (Kupka et al., 2022). Bipolar I disorder with rapid cycling has not been considered at the patient’s primary diagnosis because the severity of manic and depressive episodes are not enough to confirm the presence of bipolar I disorder.
Reflections:
The priary diagnosis for the patient is cyclothymic disorder. The main lesson learned from the case study is that an accurate diagnosis for a patient with psychological issues requires a comprehensive assessment of symptoms and the application of critical thinking processes (Kupka et al., 2022). The legal/ethical consideration that the mental health professional must consider is respecting the patient’s cultural beliefs and values regarding mental health issues and their treatment. Patient education is a key social determinant of health and health promotion strategy that the mental health professional should apply to enhance the her literacy and self-care management.
Case Formulation and Treatment Plan
What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition (DSM-5). American Psychiatric Association.
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition-Text Revision (DSM-5-TR). American Psychiatric Association.
Kupka, R., Keck, P. & Solomon, D. (2022). Rapid cycling bipolar disorder: Epidemiology, pathogenesis, clinical features, and diagnosis. UpToDate, https://www.uptodate.com/contents/rapid-cycling-bipolar-disorder-epidemiology-pathogenesis-clinical-features-and-diagnosis#:~:text=Bipolar%20disorder%20is%20characterized%20by,unresponsive%20to%20lithium%20%5B3%5D.