• Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided.
•  Include at least five scholarly resources to support your assessment and diagnostic reasoning.

• Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was 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 in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
• Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
• Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.

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CASE STUDY DETAILS

L is a 27-year-old registered nurse 4 years experience as a nurse. L began having manic episodes while at work in a diabetic clinic and nursing home where she works bringing the attention from administration of her clinic and nursing home. She began yelling and scaring patients into unscheduled fire drills and the possibility of an active shooter attack to prepare everyone of the threat. However she was doing this randomly on her own without explaining to her superiors why she is doing this. Before she could be fired she quit her job and began working at Wal-Mart as a cashier stating needed a change and the hospital sitting did not understand her, but when Stephanie went to see her at Wal-Mart manager stated she spends most of her time in the back storage room pacing or crying. Sister that lives with her and her 4 year old son stated, L is not sleeping well, spending long hours in conversations about philosophy and how reality is based on emotions. L’s sister Stephanie is very concerned L has something very serious going on. She has never acted like this always been clear headed and down to earth person until last year. She wants to be an astronaut next and states she is smarter than everyone at NASA and can actually make a rocket to go to mars. L has increased in high risk behaviors, such as smoking weed, drinking more often and having multiple sexual partners weekly that is completely unlike her history. Family states she had not been with any man since her sons father left her so she could focus on school and career. Stephanie even advising against this while her 4 year old son lives at their home, L states sees nothing wrong does not understand why everyone is “attacking her” about her life. When anyone tried to ask why she is acting this way and explained how her actions are not like her L becomes increasingly irritable and intolerant of anyone who disagrees with her lifestyle or rationalizations.

Now, patient L is living with her parents and is recommended to be been placed on a mood stabilizer, and her psychiatrist is requesting adjunctive psychotherapy for his bipolar disorder.  The patient’s family is surprised by the diagnosis, but they acknowledge that L had early problems with anxiety during pre-nursing school time while dating her high school boyfriend, followed by some periods of withdrawal and depression during her adolescence, was never hospitalized grew out of behavior.  Her family is eager to be involved in treatment, if appropriate.

NKDA

Medical history- c-section, seasonal allergies, insomnia

Non tobacco user

SYMPTOMS

• Alcohol Use
• Depression
• Elevated Mood
• Impulsivity
• Irritability
• Mania/Hypomania
• Mood Cycles
• Risky Behaviors

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DIAGNOSES AND RELATED TREATMENTS

1. BIPOLAR DISORDER

PRAC 6645:

Subjective:

CC (chief complaint): “manic episodes”

HPI: L, a 27-year-old registered nurse, initially experienced manic episodes at her diabetes clinic and nursing home employment, which grabbed the management’s attention. She shouted and frightened them into impromptu fire drills and active shooter threats to prepare them. She did it arbitrarily without alerting her superiors. Before being dismissed, she quit and became a Walmart teller, stating she wanted a change and that the medical personnel did not fully understand her. When Stephanie visited her, the Walmart manager said she spends much of her time pacing or sobbing in the rear storage room. The sister who lives with L and her 4-year-old says L cannot sleep because of her sister’s philosophical discussions on how emotions influence reality. She was usually smart and grounded until last year. L now uses marijuana, drinks much, and has numerous weekly sex partners, unlike before. Her family says she stopped seeing men when her sons’ father left her to focus on school and job. Despite Stephanie’s advice and her 4-year-old kid living at their home, L says she sees nothing wrong and does not understand why everyone is “attacking her” over her life. L becomes more furious and insufferable when someone attempts to explain why she is acting this way and how it varies from her regular behavior.

Past Psychiatric History:

• General Statement: The patient, who lives with her parents, is advised to start taking a mood stabilizer and receiving adjunctive psychotherapy for her bipolar condition.
• Caregivers (if applicable): Parents
• Hospitalizations: none
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: L struggled with anxiety at first while attending pre-nursing school and dating her high school partner, and she also had moments of sadness and withdrawal throughout her teens. Despite these issues, L never needed hospitalization and eventually outgrew her behavior.

Substance Current Use and History: Frequently drinks alcohol and marijuana use. She does not however use tobacco.

Family Psychiatric/Substance Use History: denies the existence of a mental health or drug uses disease in the family.

Psychosocial History: L lives at her parents’ home. L has been a nurse for 4 years and is a registered nurse. She resigned from her position and started working as a cashier at Walmart before she could be dismissed from the diabetes clinic where she was employed. L is having trouble sleeping because of her sister’s lengthy chats about philosophy and how emotions shape reality, according to the sister who shares her home with her and her 4-year-old kid. According to her family, she stopped dating men when her boys’ father walked out on her so she could concentrate on her studies and work.

Medical History: seasonal allergies, c-sections, and insomnia

• Current Medications: None
• Allergies: Seasonal allergies.

• Reproductive Hx: Heterosexual. regular periods of menstruation. denies having ever had STDs.

ROS:

• GENERAL: denies having a fever, generalized body weakness, weight changes, exhaustion, nausea, or vomiting.
• HEENT: Head: denies any headaches or injuries. No redness, discharge, blurriness, or tears from the eyes. No ringing, itching, or discharge in the ears. Nose: denies having a runny or congested nose. Tonsillitis, a painful throat, or trouble swallowing are denied.
• SKIN: denies itching, hives, rashes, or eczema.
• CARDIOVASCULAR: denies experiencing chest tightness, dyspnea, edema, cyanosis, or palpitations.
• RESPIRATORY: denies having chest discomfort, sneezing, or breathing difficulties.
• GASTROINTESTINAL: denies experiencing bowel changes, vomiting, diarrhea, constipation, stomach pain, or a hernia.
• GENITOURINARY: denies experiencing urgency, dysuria, nocturia, discharge, or painful urinating.
• NEUROLOGICAL: denies having a headache, becoming unconscious, or changing eyesight.
• MUSCULOSKELETAL: joints with a full range of motion and no discomfort or irritation.
• HEMATOLOGIC: denies having bleeding issues or slow wound healing.
• LYMPHATICS: dismisses lymphedema
• ENDOCRINOLOGIC: denies having excessive thirst or polydipsia.

Objective:

Physical exam: Vitals: BP 139/83; P 77; R 17; T 99.1 O2 99.6%

Diagnostic results: WBC, RBC, and CBC tests were requested as part of a normal blood workup to check the patient’s health overall. To check for substance use problems, a blood and urine drug test was also done. To determine the impact of the psychiatric medications on the patient’s liver and renal function, LFTs and RFTs were also ordered. To rule out physical trauma as the cause of the patient’s illness, a head CT scan and X-ray are also required.

Assessment:

Mental Status Examination: The patient enters the examining room wearing age-appropriate attire and seems healthy. She is aware of time, people, and places. Her intuition is still intact. Her speech is normal, and she behaves appropriately throughout the interview. She, on the other hand, exhibits bad judgment and strange views. Her demeanor is consistent. She did, however, exhibit minor psychomotor agitation. She was also in a euthymic state. His short-term and long-term memory are both adequate. His attention is strong, and he thinks clearly. She has peculiar cognitive processes and perspectives. She admits to experiencing mood swings, manic episodes, impulsiveness, and impatience.

Differential Diagnoses:

1. Bipolar disorder: To be diagnosed with bipolar disorder, a person must have had at least one episode of mania or hypomania, according to the DSM-V diagnostic criteria (Miller & Black, 2020). The patient lives with her parents and is being prescribed a mood stabilizer, while her psychiatrist is recommending supplementary therapy for his bipolar condition. The patient’s family is astonished by the diagnosis, but they recognize that L had early difficulties with anxiety when dating her high school lover during pre-nursing school, followed by some episodes of withdrawal and sadness throughout her teens, which was never institutionalized and grew out of behavior.
2. Major Depressive Disorder: According to the DSM-V, to meet the diagnostic criteria for MDD, at least five of the following symptoms must have been present over the same two-week period: depressed mood, irritability, anhedonia, substantial weight change, poor sleep, conduct disorder or retardation, extreme fatigue, hopelessness, and diminished capacity to think or focus (Ho et al., 2020). The majority of these symptoms were present in the patient.
3. Borderline personality disorder: As stated by the DSM-V, BPD is defined by a pattern of intense and unstable interpersonal connections that alternate between extremes of idealization or devaluation (Cavelti et al., 2021). The patient must have identity disruption, which is defined as a significantly and consistently unstable self-image or sense of self.

Reflections: The patient information supplied is sufficient to facilitate the formulation of a primary diagnosis and treatment plan. The patient was diagnosed with bipolar illness and was advised to take a mood stabilizer, and her psychiatrist has requested that she have supplementary psychotherapy for her bipolar disease. For additional history taking, the PMHNP enlisted the help of numerous members of the patient’s family. However, the patient has a legal right to privacy and secrecy. The PMHNP should have additionally highlighted the benefits and drawbacks of the indicated therapy so that the patient may make an educated decision. If Healthy People 2030, which calls for attaining exceptional health, is to be realized, the patient must be convinced to look into local exercise programs to improve both her physical and mental health (Miller & Black, 2020).

Case Formulation and Treatment Plan:

Pharmacotherapy: Lithium and other mood stabilizers should be explored in the treatment of the patient’s manic episodes (McIntyre et al., 2020).

Psychotherapy: According to the American Psychological Association, cognitive behavioral therapy (CBT), which involves trying to change your thinking processes, may help with bipolar disorder (McIntyre et al., 2020).

Patient Education: Educate the patient on the importance of sticking to the treatment plan for beneficial results (Carvalho et al., 2020). The patient should also be instructed on how to abstain from alcohol and drugs.

Follow-up: The patient was asked to return to the clinic in four weeks to have the efficacy of the medication evaluated further.

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek-approved clinical site during this quarter’s course of learning.

References

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar Disorder. New England Journal of Medicine, 383(1), 58–66. https://doi.org/10.1056/nejmra1906193

Cavelti, M., Thompson, K., Chanen, A. M., & Kaess, M. (2021). Psychotic symptoms in borderline personality disorder: developmental aspects. Current Opinion in Psychology, 37, 26–31. https://doi.org/10.1016/j.copsyc.2020.07.003

Ho, C. S. H., Lim, L. J. H., Lim, A. Q., Chan, N. H. C., Tan, R. S., Lee, S. H., & Ho, R. C. M. (2020). Diagnostic and Predictive Applications of Functional Near-Infrared Spectroscopy for Major Depressive Disorder: A Systematic Review. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00378

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., Young, A. H., & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841–1856. https://doi.org/10.1016/s0140-6736(20)31544-0

Miller, J. N., & Black, D. W. (2020). Bipolar Disorder and Suicide: a Review. Current Psychiatry Reports, 22(2). https://doi.org/10.1007/s11920-020-1130-0