NRNP 6665 Assessing, Diagnosing, and Treating Adults With Mood Disorders Essay

NRNP 6665 Assessing, Diagnosing, and Treating Adults With Mood Disorders Essay

NRNP 6665 Assessing, Diagnosing, and Treating Adults With Mood Disorders Essay

Week (enter week #): Psychiatric Evaluation of a Patient with Bipolar I Moderate, Mixed Type

College of Nursing-PMHNP, Walden University
NRNP 6665: PMHNP Care Across the Lifespan I

Psychiatric Assessment of 25-Year-Old Caucasian Female with Bipolar I Disorder (Mixed Mania /Depression Disorder, Major Depressive Disorder.
Chief complaint: The patient reports to the telehealth unaccompanied and says that “I have stopped taking my medications because I feel that they squash who I am and I don’t think I need them”.

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Subjective
HPI: The patient is a 25-year-old Caucasian Female with a history of Bipolar Disorder (Mixed Mania/ Depression Disorder). She was diagnosed with Bipolar Disorder during her teenage. The patient reports that she has had a bad experience with the medications prescribed to her. She says that Risperidone made her gain a lot of weight as well as Seroquel. She also says that Klonopin was prescribed and it made her slow down sometimes. She also took Zoloft which made her feel very high and she couldn’t sleep. The patient reports that there are times when people around her note that she looks depressed, though she does not admit it. She has sleep disturbances on several occasions, at times she sleeps for more than 12 hours when she feels crushed, and for 3-6 hours when she is excited. Her appetite varies, as sometimes will eat heavily while hardly eating at other times. She states that she enjoys having sex with different people which gives her good experience.
Past Psychiatric History:
General statement: The patient was diagnosed with Bipolar Depression, Anxiety, in her teenage years. The patient is noncompliant with her medication and has hypothyroidism.
Hospitalization: The patient has had four hospital admissions. In teenage, she was hospitalized due to lack of sleep and hallucinations. In 2017 she was admitted following an overdose of Benadryl.
Substance Current Use: The patient smokes about a pack of cigarettes per day. She has had one episode of alcohol use while she was 19 years old, and one incidence of marijuana. She does not use cocaine, stimulants/ amphetamines, hallucinogens like LSD, painkillers, or opioid medications.
Family Psychiatric/Substance Use History: The patient’s mother has bipolar disorder, and her father is in prison due to abuse of drugs. She has a brother who is schizoid.
Psychosocial History: The patient is in vocational-technical school training in cosmetology. She has a boyfriend but is not yet married, but they stay together. She is employed in her auntie’s bookstore. Her hobbies include painting and writing. She has been raised by her mother and her elder brother.
Medical History: The patient has hypothyroidism for which she is under medication.
Current Medications: The patient has tried Zoloft(Sertraline), Klonopin(Clonazepam), Seroquel(Quetiapine), and Risperidone but she is not compliant.
Allergies: She has no known food or drug allergies and does not have any reactions to environmental allergies or medical products.
ROS: General: The patient has no headaches or fever, however, she complains of weight gain.
Eyes: HEENT- The patient denies having photophobia, double vision, tinnitus, a runny nose, a sore throat, or difficulty swallowing. She is negative for earache, nose bleeds, or hoarseness of voice.
Skin: She denies hypo/hyperpigmentation, rashes, no erosion, ulcerations, or lacerations.
Cardiovascular: She denies chest pain, palpitations, shortness of breath, or leg swelling.
Respiratory; She has no difficulty breathing, cough, or decreased exercise tolerance.
Gastrointestinal: The patient denies abdominal pain, change in bowel habits, nausea, constipation, and vomiting.
Genitourinary: She has no increased frequency, painful urination, burning sensation, passing blood in urine, vaginal discharge, or retention.
Neurological: She denies headaches, dizziness, loss of bladder/ bowel control, and paresthesia.
Musculoskeletal: She denies having joint stiffness, joint pain, myalgia, decreased range of motion, or muscle wasting.
Hematological: She denies blood transfusion,
Lymphatic: She has no swollen lymph nodes.
Endocrinologic: The patient denies excessive sweating, heat/cold intolerance, or polydipsia Objective
Vitals: B.P.- 114/68, Temp- 97.5F, R.R.- 17 breaths per minute, BMI- 26.3.
Laboratory tests: Full blood count with differential count, thyroid function tests (TFTs), liver function tests (LFTs), renal profile, and complete metabolic profile (CMP).
and sexual dysfunction.
ASSESSMENT:
Mental State Examination
Appearance and Behavior: The patient is a 25-year-old Caucasian lady with a normal gait, she is appropriately dressed and has well-maintained hair, is appropriate for the stated age, does not have abnormal movements, and maintains eye contact. He shows no mannerisms and maintains an upright posture. During the interview, she keeps on chuckling.
Speech: Her speech is normal and coherent; she shares a conversation with a normal laryngeal tone.
Mood and Affect: Calm. Affect appropriate to the situation, however, when the interviewer repeats some questions for her, she is annoyed.
Thought content: Logical, and no psychotic illusions. She has had one episode of suicidal attempt with Benadryl overdose in 2017, though she states cannot attempt to harm herself since then.
Judgment: Realistic, with regular insight. She has grandiose delusions and insists that she would sell her paintings to celebrities and also do make-up for them.
Orientation: She is well-oriented to time, place, and person.
Memory: Immediate, recent, and remote, all intact, her concentration is good.
Intellectual: Language skills intact, named objects correctly.
Diagnostic Impression
Bipolar I Disorder Most Recent Episode Mixed, Moderate(F31.62)
DSM 5-TR criteria include both manic episodes and major depressive episodes nearly every day for at least one week and these features cause significant occupational or social dysfunction (Bartoli et al,.2020). Moreover, the symptoms are not caused by any underlying medical condition or due to substance abuse. The disturbance in mood is not attributable to grieving or loss experience and patients also have sleeping disturbance and eating disorders. The patient has both depressed and manic episodes occurring on different occasions. She reports that at times she is very energetic, with people complaining that she has increased talkativeness and will hardly sleep for more than 4 hours. In a depressed state, she eats a lot, does not go to work, and sleeps for more than 12 hours.
Major Depressive Disorder, recurrent, Moderate. (F33.2)
According to the DSM-5 criteria for diagnosing MDD patients should have two or more episodes of depressed mood, loss of interest, and increased fatigue another criterion includes disturbed sleep and eating (Hasin et al., 2018). The patient reports that at times she feels so depressed that she does not go to work. During these times she usually eats a lot of food and sleeps most of the day.
Brief psychotic disorder (F23)
The DSM-5 criteria for this disorder include at least one positive symptom such as delusions, hallucinations, and or catatonic behavior. The symptoms according to Parker (2019) do not persist for more than one day or a month. The patient reports that one day she was hospitalized after being found dancing in the night with a guitar which she does not remember. She has delusions that she would be selling her paintings to movie stars.
Reflection
I agree with my preceptor on handling this case of a patient with Bipolar 1 disorder, and I am convinced that she handled it with a professional and holistic approach. However, the patient has not been managed well to address her mood disorders. The preceptor has not implored psychotherapy options for the patient which I am going to recommend for her. From the interview, social determinants of health have been explored for the patient such as evaluating suicidal ideation, and risky sexual behavior as the interview inquired about the patient’s medical history.
Case Formulation and Treatment Plan
Pharmacologic Treatment: I would consider mood stabilizers for the patient for maintenance treatment. I would prescribe Lithium carbonate 600 mg P.O QID since lithium is effective in manic, depressive, and mixed relapses which would be very effective for the patient and decreases incidences of suicide (Rakofsky et al., 2022). I would also prescribe Fluoxetine(Prozac) 20 mg P.O. every morning as it approved by the FDA for treatment of bipolar disorders. It does not cause any significant weight gain as the patient been complaining with other medications.
Alternative Therapies and Non-Pharmacological Treatment: I educated the patient on the need for Psychotherapy modalities such as Cognitive Behavioral Therapy which is very effective in Bipolar Disorder as it focuses on identifying challenging negative and irrational thoughts (Miklowitz et al., 2021). It minimizes the likelihood of relapses and helps maintain long-term stability.
Follow-up. I would review the patient in 2 weeks’ time. Laboratory: Advised the patient on the need for serial measurement of serum lithium concentration for toxicity levels.
I advised the patient on the side effects of lithium such as hypothyroidism since she has the condition, so she would be monitored frequently and modifications made appropriately.
Educated the patient on the need for drug compliance to reduce depressive and manic episodes (M’Bailara et al., 2019). Also advised her on the need for regular physical exercise and maintaining a well-balanced diet I also advised her on the need for smoking cessation. I would also provide her with a suicidal hotline phone number, 800-273-8255.
Referrals: I would refer her to an endocrinologist for review and evaluation of her hypothyroidism.

References
Bartoli, F., Crocamo, C., & Carrà, G. (2020). Clinical correlates of DSM-5 mixed features in bipolar disorder: A meta-analysis. Journal of affective disorders, 276, 234–240. https://doi.org/10.1016/j.jad.2020.07.035
Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States. JAMA Psychiatry, 75(4), 336–346. https://doi.org/10.1001/jamapsychiatry.2017.4602
M’Bailara, K., Minois, I., Zanouy, L., Josse, F., Rouan, E., Maîtrot, A., Sportich, J., Roux, S., Jutant, A., Deloge, A., Desage, A., & Gard, S. (2019). L’éducation thérapeutique : un levier pour modifier les perceptions du trouble bipolaire chez les aidants familiaux [Therapeutic education: A lever to change perceptions of bipolar disorder in family caregivers]. L’Encephale, 45(3), 239–244. https://doi.org/10.1016/j.encep.2018.11.004
Miklowitz, D. J., Efthimiou, O., Furukawa, T. A., Scott, J., McLaren, R., Geddes, J. R., & Cipriani, A. (2021). Adjunctive Psychotherapy for Bipolar Disorder: A Systematic Review and Component Network Meta-analysis. JAMA Psychiatry, 78(2), 141–150. https://doi.org/10.1001/jamapsychiatry.2020.2993
Parker G. (2019). How Well Does the DSM-5 Capture Schizoaffective Disorder? Canadian Journal of Psychiatry. Revue canadienne de psychiatrie, 64(9), 607–610. https://doi.org/10.1177/0706743719856845
Rakofsky, J. J., Lucido, M. J., & Dunlop, B. W. (2022). Lithium in the treatment of acute bipolar depression: A systematic review and meta-analysis. Journal of affective disorders, 308, 268–280. https://doi.org/10.1016/j.jad.2022.04.058

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Assessing, Diagnosing, and Treating Adults With Mood Disorders

It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.

In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.

Resources

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

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

Chapter 6, “Bipolar Disorders”

Chapter 2, “Neurodevelopmental Disorders and Other Childhood Disorders”

Section 2.9, “Depressive Disorders and Suicide in Children and Adolescents” (pp. 174-180)

Section 2.10, “Early-Onset Bipolar Disorder” (pp. 181-184)

Chapter 7, “Depressive Disorders”

Chapter 21, “Psychopharmacology”

Chapter 22, “Other Somatic Therapies”Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.

Chapter 11, “Mood Disorders”

Document: Focused SOAP Note Template

Download Focused SOAP Note Template

Document: Focused SOAP Note Exempla

Download Focused SOAP Note Exemplar

Required Media

CrashCourse. (2014, September 8). Depressive and bipolar disorders: Crash course psychology #30

Links to an external site. [Video]. YouTube. https://youtu.be/ZwMlHkWKDwM https://www.youtube.com/watch?v=ZwMlHkWKDwM&t=1sLinks to an external site.

Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. https://waldenu.instructure.com

Medication Review

Depression Premenstrual dysphoric disorder Seasonal affective disorder (MDD with Seasonal Variation)

agomelatine

amitriptyline

amoxapine

aripiprazole

(adjunct)

brexpiprazole (adjunct)bupropion

citalopram

clomipramine

cyamemazine

desipramine

desvenlafaxine

dothiepindoxepin

duloxetine

escitalopram

fluoxetine

fluvoxamine

iloperidone

imipramine

isocarboxazid

ketamine

lithium (adjunct)

l-methylfolate (adjunct)lofepramine

maprotiline

mianserin

milnacipran

mirtazapine

moclobemide

nefazodone

nortriptyline

paroxetine

phenelzine

protriptyline quetiapine (adjunct)

reboxetine

selegiline

sertindole

sertraline

sulpiride

tianeptine

tranylcypromine

trazodone

trimipramine

venlafaxine

vilazodone

vortioxetine

citalopram

desvenlafaxine

duloxetin

eescitalopram

fluoxetin

eparoxetine

pepexev

sarafe,

sertraline

venlafaxine Bupropion HCL extended-release

Bipolar depression Bipolar disorder (mixed Mania/Depression Bipolar maintenance Mania
lithium (used with lurasidone)

lurasidone

olanzapine-fluoxetine combination (symbyax)

quetiapine

valproate (divalproex) (used with lurasidone) aripiprazole

asenapine

carbamazepine olanzapine

ziprasidone

aripiprazole

lamotrigine

lithium

olanzapine aripiprazole

asenapine

carbamazepine

lithium

olanzapine

quetiapine

risperidone

valproate (divalproex)

ziprasidone

To Prepare

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)

The Assignment

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.).

By Day 7 of Week 4

Submit your Focused SOAP Note.

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

To submit your completed assignment, save your Assignment as WK1Assgn+last name+first initial.

Then, click on Start Assignment near the top of the page.

Next, click on Upload File and select Submit Assignment for review.

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