NRNP_6665 Depression and Bipolar

  • Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
  • Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
  • Review the video, Case Study: Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
  • Consider what history would be necessary to collect from this patient.
  • Consider what interview questions you would need to ask this patient.
  • Consider patient diagnostics missing from the video: 

Provider Review outside of interview:

Temp 98.2  Pulse  90 Respiration 18  B/P  138/88

Laboratory Data Available: 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)

Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

  • Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? 
  • Objective: What observations did you make during the psychiatric assessment?  
  • Assessment: 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.
  • 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.
  • Reflection notes: 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.).

Answer

 

Depression and Bipolar

Patient details:

Petunia Park, Female, 25 years.

Date of interview: December 1, 2020

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., a 25-year-old American lady, comes for a mental health evaluation. She is currently not on any medication. She has a positive history of beginning and stopping drug therapy because she believes they suffocate her personality. She desires to discover a drug without harmful side effects to help her mental health. Petunia has been hospitalized four times for mental health reasons, the most recent being in the spring, and denies having gone through detox or residential rehab. She admits to making one suicide attempt in 2017 but denies any current suicidal ideation or self-harm behavior. Petunia has a history of depression, anxiety, and the possibility of bipolar disorder. She describes previous medications she has been on, including Zoloft, risperidone, Seroquel, and Klonopin, all of which have had varying side effects. She works at her aunt’s bookstore and is most tolerant of her occasional depressive episodes. She is studying cosmetology at a vocational training center. Petunia enjoys writing and painting in her spare time and hopes to publish her life story and sell her paintings. She admits to having a high level of sexual activity but denies any intention of causing harm to herself or others. Petunia lives with her boyfriend but visits her mother on occasion. She denies having been arrested or convicted in the past. Petunia describes her father’s verbal abuse but denies physical or sexual abuse. Following intense creativity, she experiences low energy and motivation that last about a week. During these episodes, she has less sleep and more productivity. Petunia denies experiencing significant worry, anxiety, or panic attacks.

Past Psychiatric History: Petunia has been hospitalized four times for mental health reasons, the most recent being in the spring, and denies having gone through detox or residential rehab. She admits to making one suicide attempt in 2017 but denies any current suicidal ideation or self-harm behavior.

Medication Trial: P.P. took Zoloft, which gave her a high and caused sleep problems. Risperidone and Seroquel both resulted in weight gain. Klonopin made her sluggish, but she cannot recall the names of her other medications. Her most recent prescription, which she believes began with an “L,” suppressed her creativity.

Psychotherapy or Previous Psychiatric Diagnosis: Petunia has a history of depression, anxiety, and the possibility of bipolar disorder. She describes previous medications she has been on, including Zoloft, risperidone, Seroquel, and Klonopin, all of which have had varying side effects.

Substance Use History: Petunia smokes one pack of cigarettes daily but refuses to quit. She stopped drinking alcohol when she was 19 because of the adverse effects. She tried marijuana once and got paranoid. She denies ever using cocaine, stimulants, inhalants, sedative medications, hallucinogens, opiates, or synthetic substances. Petunia has not had any blackouts, seizures, or visual hallucinations due to substance abuse.

Family Psychiatric/substance Use History: Petunia reveals that her mother has bipolar disorder, and her father was incarcerated for drug-related offenses. She knows her brother’s possible schizophrenia but admits he has not sought medical attention.

Medical History

  • Current Medications: The most recent medicine she stopped consuming, which she believes began with an “L,” suppressed her creativity. She is on hypothyroidism medication and a birth control pill for polycystic ovaries.
  • Allergies: no reported drug, food, or environmental allergy.
  • Reproductive Hx: Her last menstrual period was in last month; she did not mention the date; she denies being pregnant, is not nursing or lactating, she is on birth control pills for polycystic ovaries, and has high sexual activity with multiple partners.

ROS:

GENERAL: Petunia denies significant weight loss, weakness, body temperature changes, chills, or fatigue.

HEENT: Eyes: P.P. has no visual changes, yellowing of sclerae, hearing loss, nasal congestion, sneezing, runny nose, or a sore throat.

SKIN: denies having any rash or itch.

CARDIOVASCULAR: No report of chest pain, palpitations or edema.

RESPIRATORY: No shortness of breath, sputum production, or cough.

GASTROINTESTINAL: P.P. denies nausea, vomiting, any changes in appetite, or diarrhea. She also reports no blood in her stool.

GENITOURINARY: she has no urinary symptoms like burning, urgency, or unusual odor or color.

NEUROLOGICAL: Petunia denies headaches, dizziness, paralysis, ataxia, syncope, numbness, or tingling extremities. There are no changes in bowel or bladder control.

MUSCULOSKELETAL: No muscle or joint pain.

HEMATOLOGIC: P.P. denies any bruising or bleeding.

LYMPHATICS: She has no enlarged nodes or a history of spleen removal.

ENDOCRINOLOGIC: No report of excessive sweating, intolerance to heat or cold, extreme thirst, or urination.

Objective:

Diagnostic results: None

Assessment:

Mental Status Examination: P.P. is a 25-year-old American lady who appears to be her age. She is well-groomed and dressed correctly for the weather. Her overall demeanor appeared cooperative and actively involved. Petunia acted normally throughout the session, making appropriate eye contact and using appropriate body language. Her mood seemed euthymic, with no apparent signs of sadness or elation. Her affect matched her mood, displaying appropriate emotional reactions to the conversation. Petunia’s speech was concise, coherent, and purposeful, with no noticeable abnormalities like pressed or slowed speech. Her thought processes appeared organized, rational, and cohesive, without tangentiality or idea flight. There was no evidence of thought blockage or perseveration. Petunia denied having suicidal thoughts and said she never engages in self-harming behaviors. She denied experiencing any perceptual disruptions, such as hallucinations or illusions. Her cognition appeared intact as she responded to questions about her details, current date, and location with accuracy and detail. Petunia demonstrated a good understanding of her mental health issues and desired to seek other treatments that do not interfere with her creativity. Based on her responses to questions about previous hospitalizations and suicidal ideation, her judgment appeared intact.

Diagnostic Impression: Bipolar Disorder

Mania or hypomania episodes that alternate with depressive periods are the hallmark of bipolar disorder (B.D.).According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a person must have had at least one manic or hypomanic episode and one major depressive episode to be diagnosed with Bipolar Disorder (National Institute of Mental Health, 2020). A discrete time of significantly elevated or expansive mood that lasts for at least a week is a manic episode (Jain & Mitra, 2023). A hypomanic episode is comparable to a manic episode but lasts less time and has milder symptoms that never seriously affect one’s ability to function or necessitate hospitalization. Given the patient’s history of mood swings, the most likely diagnosis is bipolar illness. The patient reports having periods of extreme energy, a diminished need for sleep, racing thoughts, enhanced creativity, participating in unsafe behaviors like promiscuity, excessive talking, and feeling disoriented, all of which are signs of a manic episode. Following these episodes are periods of poor mood, lack of energy, and decreased interest, indicating depressive episodes. Additionally supporting this diagnosis is the patient’s family history of bipolar disorder.

Major Depressive disorder

An alternative diagnosis for Petunia Park’s symptoms is major depressive disorder (MDD). According to Kennedy (2022), MDD is characterized by enduring emotions of depression, anhedonia, and not enjoying activities one previously had fun in. However, Petunia’s descriptions of times of high mood, a reduction in the need for sleep, and hazardous activities, which are more typical of bipolar disorder, cannot be explained by MDD alone. Petunia’s history of manic episodes led to the exclusion of MDD as a primary diagnosis because it failed to capture the complete range of her symptoms adequately.

Borderline Personality Disorder

The characteristics of Petunia Park could also fit the differential diagnosis of borderline personality disorder (BPD). Emotional instability, impulsive behavior, and the dread of abandonment are traits of BPD (Chanen et al., 2020). The patient mentions unstable relationships, impulsive behavior, and past instances of emotional dysregulation. The patient also references other BPD characteristics, including emptiness and a history of self-harm. Petunia has unstable emotions and self-destructive activities, but bipolar disorder symptoms are more closely aligned with her symptoms, including discrete periods of high mood and grandiosity. Petunia’s problems have persisted since adolescence, whereas BPD often shows signs in early adulthood. Therefore, BPD was ruled out as the primary diagnosis in favor of bipolar illness based on the occurrence of manic/hypomanic episodes and the history of her symptoms.

Reflection.

Dr. Moore did a great job dealing with the patient, especially when she became agitated about mundane things like his inquiring about her family. The doctor’s skillful explanation of why this data is necessary has prompted P.P. to reveal even more of her thoughts and feelings. When making a diagnosis, I discovered that it is crucial to consider the patient’s current condition and family history. To better arrive at a diagnosis in the future, I would make it a point to inquire further into the patient’s personal and family mental history.

I understand that there are legal and ethical factors beyond only confidentiality and consent that must be considered. In particular, it is crucial to analyze the role of informed consent in psychiatric treatment, the patient’s competence to make treatment decisions, and involuntary hospitalization (Zakhari, 2021). Knowledge of the social determinants of health is essential When providing proper care and removing obstacles to a patient’s treatment plan (Boland et al., 2022). Patient characteristics such as age, ethnicity, and medical history must be considered while designing interventions and developing preventative measures. Medication adherence, handling stress, and positive coping strategies should all be central tenets of any health promotion program to improve a patient’s quality of life. Risk factors in the patient’s environment should be considered, and plans should be made to lessen their effect on mental health.

Case Formulation and Treatment Plan 

P.P. has been on various medications for her mental health condition and wishes to get one with the least or no side effects. The most significant concern, however, would be risky sexual behavior, suicide attempts, mania, and depression. I would order a complete blood count (CBC) and comprehensive metabolic panel (CMP) to examine any underlying medical issues and measure her general health status. I would also evaluate her thyroid function and direct treatment for thyroid disease through a thyroid-stimulating hormone (TSH) test. She needs to be put on levothyroxine for her hypothyroidism (Eghtedari & Correa, 2019). A urine drug test is necessary to evaluate any recent drug use.

Referrals: Referral for treating thyroid illness to a primary care physician (PCP). I recommended therapy with a trained psychotherapist to address risky conduct, inadequate coping skills, trauma, and interpersonal instability.

Medications: Topiramate 50mg BID: Begin for improved sleep and mood stabilization while closely monitoring for adverse effects and effectiveness. The drug can be used as an off-label treatment with patient-specific drug effects such as dizziness and psychomotor slowing (Fariba & Saadabadi, 2023), which P.P. needs to be informed about. Citalopram 20 mg once daily will be started with careful titration and monitoring of side effects for mood stability, addressing depression and mood swings (drugs.com, 2018).

Education: There is a need to emphasize the value of adhering to prescribed therapies and provide information on the risks and advantages of medications, including any potential adverse effects. I will teach Petunia about the possible drug-substance interactions so she can make an informed choice. Petunia will regularly see a therapist to discuss her dangerous sexual conduct, inadequate coping skills, trauma, and interpersonal instability. I have outlined appointment times for therapy and psychiatry services to track development, alter medications as necessary, and offer support.

Follow-up: To track treatment response, gauge medication side effects, and gauge therapy progress, follow-up visits have initially been scheduled every two weeks. To track potential adverse effects and inform treatment choices, order and evaluate the appropriate test.

References

Boland, R. J., Verduin, M. L., & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

Chanen, A. M., Nicol, K., Betts, J. K., & Thompson, K. N. (2020). Diagnosis and treatment of borderline personality disorder in young people. Current Psychiatry Reports, 22(5). https://doi.org/10.1007/s11920-020-01144-5

drugs.com. (2018). Citalopram. Drugs.com; Drugs.com. https://www.drugs.com/citalopram.html

Eghtedari, B., & Correa, R. (2019). Levothyroxine. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539808/

Fariba, K. A., & Saadabadi, A. (2023). Topiramate. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554530/#:~:text=Topiramate%20is%20a%20medication%20used

Jain, A., & Mitra, P. (2023, February 20). Bipolar affective disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558998/

Kennedy, S. H. (2022). Core symptoms of major depressive disorder: Relevance to diagnosis and treatment. Dialogues in Clinical Neuroscience, 10(3), 271–277. https://doi.org/10.31887/dcns.2008.10.3/shkennedy

National Institute of Mental Health. (2020). Bipolar disorder. National Institute of Mental Health; National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder

Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing.

 

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