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Patient Name: XXX
MRN: XXX
Date of Service: 02-13-2020
Start Time: 09:00 End Time: 10:49
Billing Code(s): 90853, 90791
Accompanied by: Mother
CC: 33-year-old male followed up post discharge from inpatient psychiatric stay
HPI: The patient was admitted inpatient for mental health issues two weeks ago following several weeks of uncontrolled mania and irritability. He had been admitted to the emergency room following an episode of violent aggression against his mother. He initially presented with a depressed mood, agitation, and confusion about the events leading up to his admission. Since admission, he has been taking medication (Depakote 500mg) and receiving regular inpatient psychiatric sessions until his discharge three days ago.
S- The patient reports that he is “doing much better” post-discharge and is “feeling more in control”. He states his mood is stable and his irritability has decreased significantly. He reports no suicidal or homicidal ideation. He has been compliant with his medications and has noticed no side-effects. He reports that he has been sleeping better and getting exercise.
Crisis Issues: The patient denies any active crisis issues.
Reviewed Allergies: NKA
Current Medications: Depakote 500mg Daily
ROS
Constitutional: Patient reports feeling better and more in control post-discharge from inpatient psychiatric care.
Eyes: Patient has no vision changes or vertigo.
ENT: Patient reports no hearing difficulties or ear pain.
Cardiovascular: No chest discomfort,
Respiratory: Patient has no cough
GI: No , constipation, or stomach discomfort.
GU: Patient is asymptomatic.
Musculoskeletal: No , stiffness, or arthralgias.
Skin: No lesions.
Neurologic: Patient has no numbness, tremors, or proximal muscle weakness.
Endocrine: Patient has no heat or cold intolerance, weight gain or loss, excessive thirst or urination, or excessive sweating.
Hematologic: Patient denies any easy bruising or bleeding.
O-
Vitals: T 97.4, P 82, R 14, BP 120/72
PE: (not always required and performed, especially in psychotherapy only visits)
Labs: CBC, Lytes, and TSH WNL
Results of any Psychiatric Clinical Tests: PANSS (Positive and Negative Symptom Scale)= 84
MSE:
Mark Thomson is a 33 year old white male who presents to the outpatient office accompanied by his mother. He is dressed casually and is cleanly groomed. His mood is neutral and his affect is appropriate to the conversation. He appears cognizant of his surroundings, is oriented x3, and has good eye contact. His speech is fluent and his thought process is coherent. He denies any current suicidal or homicidal ideation, auditory or visual hallucinations, or delusions. His judgment, insight, and reliability appear intact and he is able to provide informed consent.
A - with (ICD-10 code)
Differential Diagnoses:
1. Major Depressive Disorder – F32.9 (Abdoli et al., 2021)
2. Schizoaffective Disorder – F25.0 (Archibald, 2019)
3. Psychotic Disorder – F29 (Jongsma et al., 2019).
MDD was considered. MDD symptoms include depression, anhedonia, poor focus, weariness, and suicidal ideas persisting over two weeks (Abdoli et al., 2021). Mark's mood has stabilized after his initial depression, he has no concentration issues, and he denies suicide ideas. He also lacked dysphoria and anhedonia for MDD.
Schizoaffective disorder was considered. According to the DSM-5, manic episodes and depressive symptoms must co-occur (Archibald, 2019). It was ruled out since Mark solely experiences manic symptoms.
Third differential was psychotic disorder. Diagnosis involves delusions, hallucinations, or incoherent speech (Jongsma et al., 2019). Mark had grandiose delusions but no other symptoms or speech confusion, thus psychotic illness seemed unlikely.
Mania, including grandiose delusions, anger, and labile mood, led to the diagnosis of bipolar illness, current episode extreme manic. The patient met DSM-5 criteria for current episode severe manic. Based on this diagnosis, the patient began pharmacological and non-pharmacological therapy to control his symptoms and stabilize.
Definitive Diagnosis:
F30.2, Bipolar Disorder, Current Episode Severe Manic (Carvalho et al., 2020)
After eliminating the three differential diagnoses, the patient's clinical picture fit bipolar illness, current episode intense manic. The DSM-5 defines mania as abnormal and persistently elevated, expansive, or irritable mood and at least three of the following symptoms: inappropriate/excessive grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, psychomotor agitation, increased involvement in pleasurable activities with a high potential for painful consequences, or hyper-sexuality (Carvalho et al., 2020).
The case study patient had mood lability and elevated mood, excessive grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, hyper-sexuality, and increased involvement in potentially painful activities. The patient had no psychosis, anxiety, or sadness, supporting the diagnosis of bipolar disorder.
The DSM-5 and clinical picture confirmed bipolar illness, present episode intense manic (Carvalho et al., 2020). Based on this diagnosis, the patient began pharmacological and non-pharmacological therapy to control his symptoms and stabilize.
P- Increase the daily dose of Depakote to 1000mg
Continue outpatient counseling: twice weekly psychotherapy sessions involving cognitive-behavioral therapy (CBT)
Non-pharmacological Tx:
1. Exercise (Rosson et al., 2022)
2. Relaxation techniques
3. Time management (Rosson et al., 2022)
4. Positive self-talk
5. Increased social engagement (Rosson et al., 2022)
6. Psychoeducation about bipolar disorder
7. Sleep Hygiene (Rosson et al., 2022)
8. Stress management strategies
9. Socialization activities (Rosson et al., 2022)
10. Mindfulness-based coping
Pharmacological Tx: (be specific and give detailed Rx information)
1. Depakote tablests 1000mg daily (Jongsma et al., 2019).
2. Lamotrigine 25mg daily
3. Quetiapine 50mg twice daily (Jongsma et al., 2019).
4. Omega-3 supplements
5. Fluoxetine 10mg daily(Jongsma et al., 2019).
Education:
1. Self-monitoring of mood and symptom fluctuations(Jongsma et al., 2019).
2. Differentiating between manic symptoms and behaviors
3. Ways to manage stress and triggers of mania
4. Balancing sleep, relaxation, and exercise (Jongsma et al., 2019).
5. Recognizing early warning signs of manic or depressive episodes
6. Identifying and managing potential side-effects of medication
7. Achieving and maintaining proper nutrition 8. Building and practicing coping mechanisms
9. Disclosing symptoms to family, friends, employers, and healthcare professionals
10. Managing family dynamics (Jongsma et al., 2019).
11. Identifying and utilizing additional support resources
12. Engaging in open communication with healthcare providers (Jongsma et al., 2019).
13. Making reasoned decisions about medication changes
14. Techniques to enhance medication adherence 15. Proactive strategies to reduce risk of relapse (Jongsma et al., 2019).
Follow-up: The patient will follow up in one week for medication management and will continue with the above-outlined interventions.
Referrals: The patient will be referred to a psychiatrist and nutritionist
References
Abdoli, N., Salari, N., Darvishi, N., Jafarpour, S., Solaymani, M., Mohammadi, M., & Shohaimi, S. (2021). The global prevalence of major depressive disorder (MDD) among the elderly: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 132. https://doi.org/10.1016/j.neubiorev.2021.10.041
Archibald, L. (2019). Alcohol Use Disorder and Schizophrenia and Schizoaffective� Disorders. Alcohol Research: Current Reviews, 40(1). https://doi.org/10.35946/arcr.v40.1.06
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
Jongsma, H. E., Turner, C., Kirkbride, J. B., & Jones, P. B. (2019). International incidence of psychotic disorders, 2002–17: a systematic review and meta-analysis. The Lancet Public Health, 4(5), e229–e244. https://doi.org/10.1016/s2468-2667(19)30056-8
Rosson, S., de Filippis, R., Croatto, G., Collantoni, E., Pallottino, S., Guinart, D., Brunoni, A. R., Dell’Osso, B., Pigato, G., Hyde, J., Brandt, V., Cortese, S., Fiedorowicz, J. G., Petrides, G., Correll, C. U., & Solmi, M. (2022). Brain stimulation and other biological non-pharmacological interventions in mental disorders: An umbrella review. Neuroscience & Biobehavioral Reviews, 139, 104743. https://doi.org/10.1016/j.neubiorev.2022.104743