Assignment Week 9 - NRNP 6635 - Case Study

1

CASE STUDY 1 3

Demographics: Female, 41 years-old Hispanic on disability. The higher level of education High School.

Setting: Private Office, follow up appointed after discharged from inpatient psych admission.

Reason for and Type of Visit: “I was admitted to a mental institution for five days after I tried to kill myself taking an overdose in my medications. They discharged me from the hospital three days ago.”

Diagnosis: 

F31.64 - Bipolar disorder, current episode mixed, severe, with psychotic features

Rating Scales: BDRS - The Bipolar Depression Rating Scale: 14

History of Present Illness: 41-year-old female, Hispanic with a previous medical history of Bipolar Disorder, perceptual disturbances, and auditory hallucinations, present to this private office for an initial psychiatric evaluation and follow up after discharge from inpatient hospitalization three days ago. The patient said she complains about her treatment and medications as prescribed by her doctor. The patient said she is not feeling depressed, or having passive death wishes and is not hearing any voices currently. Patient report normal sleep (6-7 hours) and a good appetite. The patient recognized she has a history of poor medication compliance and said she wants a referral to start an outpatient program to help her with her treatment.

Psychiatric History:

The patient was in the hospital for five days after she tried to kill herself by overdose, she was discharged three days ago. The patient state she was hearing voices telling her to kill herself, and she was following the voices. The patient ingests ten pills of clonazepam belongs to her partner. The patient with long psychiatric history with multiple psychiatric admissions. The patient state she has two previous suicidal attempts by overdose and one by jumping in front of a moving car. Patient report PHP 2 years ago. She is not attending any therapy or outpatient program at this time.

Substance Abuse History: The patient report a history of substance abuse, alcohol abuse, cocaine abuse, and cannabis abuse since her 20’s. She participated and completed a voluntary rehabilitation program ten years ago, and the patient denies any substance abuse currently. UDS review form previous hospitalization is negative.

Family Psychiatric History:

Patient report that her mother had a history of bipolar disorder and Major Depressive disorder, and she kills herself by overdose when a patient was 12 years old. The patient’s sister has a Depressive Disorder.

Medical/Surgical History: The patient doesn’t have any medical or surgical history.

Medications:

The patient was discharge from impatient hospitalization with the following medications:

Klonopin 0.5mg po bid

Prozac 20mg po qam

Zyprexa 10mg po qhs

1.    KLONOPIN

Generic Name: clonazepam

Brand Name: KlonoPIN

Class: Benzodiazepine (anxiolytic, anticonvulsant)

Side Effects: respiratory depression, dependency, abuse, seizures, suicidality, hypotension, orthostatic tachycardia, syncope, blood dyscrasias, hepatomegaly, CNS stimulation.

Patient education: Contact your primary PCP if you feel increased depression, uncommon variations in conduct, or feelings about suicide or hurting yourself; Clonazepam might cause dependence, don’t share your medication with nobody. Keep your medicine in a room or place nobody else can have access; Take the tablet totally, with a full glass of water; do not stop using this medication abruptly, or you might have an unfriendly withdrawal warning sign, as well as seizures (convulsions).

2.    PROZAC:

Generic Name: fluoxetine

Brand Names: PROzac, PROzac Weekly, Sarafem

Class: SSRI (Selective serotonin reuptake inhibitor); often classified as an antidepressant.

Side Effects: Nausea, drowsiness, dizziness, anxiety, trouble sleeping, loss of appetite, tiredness, sweating, or yawning may occur.

Patient Education: Share with your PCP all the medications you are taking, including the over the counter medications. Report to your PCP if you have feelings and thoughts of suicide or self-harm. You need to visit your PCP frequently to check your progress. Do not change the dosage or the frequency of this mediation without consulting your doctor.

3.    ZYPREXA:

Generic Name: olanzapine

Brand Names: ZyPREXA

Class: Atypical antipsychotic (serotonin-dopamine antagonist; second generation; mood stabilizer)

Mechanism of Action: mechanism of action is unknown; antagonizes dopamine, serotonin 5-HT2, and other receptors (thienobenzodiazepine)

Metabolism: liver extensively; CYP450

Side Effects: Drowsiness, dizziness, lightheadedness, stomach upset, dry mouth, constipation, increased appetite, or weight gain may occur.

Patient Education: Avoid doing activities outdoors, including exercise direct under the sun or high humidity, do not use hot tubs. Drink fluids and dress lightly; stand up slowly when you are in a sitting or lying position; this medication can be taken with or without food. Follow your PCP directions.

 Mental Status Exam: 

Appearance and behavior: fair hygiene and groomed, cooperative

Eye contact: fair

Level of Alertness: Alert

Mood: euthymic

Affect: congruent

Speech: normal in volume and rate

Thought processes: linear

Thought content: goal-directed

Perceptual disturbances: none report (hx. of Auditory Hallucinations)

Insight/judgment: Good

Suicide ideations/intent/plans: denied

Homicidal ideation/intent/plans: denied.

Points Discussed in Visit: Speaking points with the preceptor

· Medication reconciliation after discharge

· Diagnostic

· Poor medication compliance

· Recommended treatment and therapy

Therapy Recommendations:

The patient is not attending any therapy currently.

The therapy recommended for Bipolar Disorder: Cognitive Behavioral Therapy (CBT) is an individual therapy motivated on the connection between the patient’s mental state, thoughts, and comportments. CBT shows the patient in what way he/she can identify negative thoughts and how to create positive and constructive ways of thinking.

Clinical Impression: 41 years old female Hispanic, with PPHx of bipolar disorder, cocaine abuse, cannabis abuse, and alcohol abuse, appears older than her chronological age. The patient appears clean, with fair eye contact. On exam, the patient is in no distress, calm, cooperative, with a linear, organized thought process. No evidence of psychosis or mania/hypomania. The patient mood is euthymic and affect congruent. The patient reports good energy, appetite, sleep (6-7h nightly), denies any suicidal ideation, and denies perceptual disturbances. She denies racing thoughts. The patient denies current issues with anxiety or panic attacks. The patient doesn’t report any other complaints currently.

Diagnosis Code: 

F31.64 - Bipolar disorder, current episode mixed, severe, with psychotic features

Treatment Recommendations:

Recommended to the patient to continue with home medications

Patient educated of medication side effects, and benefits of treatment. Patient verbalized understanding. Discussed signs of patient illness and symptom management.

Labs ordered: None at this time - Review of labs results from the previous hospitalization -

Intervention Therapy: The patient recommended to initiate CBT therapy. Practice stress management techniques and incorporate recreational techniques.

The patient referred to the PHP program of Miami Dade County.

The patient instructed to take medication as prescribed. Avoid alcohol. Avoid caffeine and continue with a healthy diet.

The patient instructed to come back for a follow-up consultation in 2 weeks or sooner if needed.

References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. DSM-5, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. (2013)

Stahl, Stephen (2015). Essential Psychopharmacology Prescriber’s Guide. Fifth Edition. New York, NY Cambridge University Press.