pt4

2

Mood Disorders in Adults

Student’s name

Instructor

Course

Date

Subjective:

CC: There are moments when I simply don't want to get out of bed," admits a 42-year-old client. I'm completely depleted in both energy and motivation. There is no spark in my creative juices."

HPI: Her mental treatment kills her creativity and personality, so she visits our office because she feels it is ineffective. As a young person, she struggled with sleep problems that necessitated treatment at a hospital. That she may have been hearing things, too. She has also been treated for a Benadryl overdose due to suicide thoughts, in addition to her sleep issues. Mood disorders, depression, and bipolar illness have all been identified during her previous therapies. She is now experiencing highs and lows. She may not have the stamina or enthusiasm to work for five days straight. In the midst of "creativity episodes," she may spend up to four days without sleeping. As a result of her erratic sleeping habits, she begins to experience hearing voices. In the midst of her creative process, she suffers from a lack of appetite as well, but the tone of the story shifts when she hits a wall.

Substance Current Use: Uses nicotine, smokes a pack daily.

Medical History:

· Current Medications: birth control pills and hypothyroidism medication.

· Allergies: Doesn't seem to be allergic to anything.

· Reproductive Hx: Menstrual cycles that are regular, a large number of sexual partners, the use of birth control, the absence of children, and the absence of STIs.

ROS:

General: petunia park appears well nourished, presentable, and in no distress. She gets slightly irritated when a question is repeated like the one about suicidal ideation. She is jovial.

HEENT: no visible head scaring or depressions, normal optic vessels and discs, hearing intact, no external mucosa, no obvious teeth issues.

Skin: no rash, prominent lesions or bruising.

Cardiovascular: no cardiac lifts or heaves.

Respiratory: no respiratory infection.

Gastrointestinal: experiences both loss of appetite and excessive eating.

Genitourinary: normal menstrual cycle.

Neurological: no headaches, sometimes hears voices.

Musculoskeletal: perfect back, patient does not report exercising.

Hematologic: no unusual bleeding, possible exhaustion.

Lymphatics: no lymph node tenderness or enlargement.

Endocrinologic: reports hypothyroidism.

Objective:

Due to her belief that medications suppress her, the patient alternates between taking them and not. She doesn't seem worried or distressed in any way. She's in a good mood and is responding to questions. The fact that she can tell the time of day and year means she is aware of her surroundings. As far as how she thinks about past meds, she is very forward and honest. How many times she was hospitalized for mental health is clear to her, including when she was initially admitted.

Diagnostic results: Despite the fact that a thyroid function test revealed hypothyroidism in the patient, this condition was not the root of her emotional instability. Drugs like Zoloft and risperidone that have been suggested in the past may be less effective now because of the disease.

Assessment:

Mental Status Examination: Based on her looks, voice, mental content, and behavior, the client seems to be in good health. In addition to being well-dressed and tidy, she is also pleasant to be around. The doctor's queries were also well-answered by the patient. She had a vague recollection of events from the past. For example, she remembers her mother being hospitalized as a teen. She also recalls the four times she was admitted to the hospital for mental health treatment. Finally, she was able to maintain her composure throughout the doctor's visit. She answered all of the questions she was asked in a succinct and to the point manner.

Diagnostic Impression: At least two weeks of deterioration in the client's ability to function are consistent with a recurrent depressive disorder (World Health Organization, 2020). For example, a cheerful client may experience a rapid depletion of energy after engaging in vigorous activity. After working for weeks at her aunt's bookshop, she feels at least five days of exhaustion. The patient may also be experiencing a maniac condition, defined by an expansive, elevated, or irritable state of mind lasting for several days (Marzani & Neff, 2021). It's not uncommon for her to go four to five days without sleeping since she's having one of those "creativity moments." Additionally, she seems disorganized and too confident due to the voices that tell her she is a genius. Also consistent with the bad judgment of crazy patients, the patient claims that she has several relationships in order to maintain her good mood. Finally, hypomania is a disease that may occur. Talkativeness and absorption in enjoyable pastimes are the hallmarks of this kind of personality disorder. At one point in time, the client claims to have been taken to the hospital by police because she was dancing about in her nightgown. She maintains that the tale was made up.

Reflections: My next session would involve informing the client of her illnesses and prescribing the best course of action for her condition. In this case, the therapist and client would have to come to an agreement on the number of sessions and their length. If there are any extra or new adjustments that the customer has observed, I'll ask about it. However, I would encourage the client to keep her ailment and treatment a secret until she is completely well again. As a part of her social life, I would also counsel her to become more active in activities such as sports, community events, and church services. Additionally, I advise her to reduce her use of substances and monitor her nutrition.

Case Formulation and Treatment Plan:

Medications: There are antidepressants and antianxiety drugs as well as antipsychotics that I would recommend for her. Her depression, mood disorder and bipolar illness would be reduced by using these drugs.

Exercise: I think she should do 30 minutes of physical activity every day for at least four days of the week. Increasing the amount of endorphins in the bloodstream would help enhance mood.

Social engagement: If she wants to improve her social life and lift her spirits, I suggest that she join a club or volunteer for an event in the community.

Avoid drug abuse: There is no health advantage to tobacco, thus she should stop using it.

Follow-up parameters: For the first two weeks of treatment, I would be monitoring the patient to see whether their mood had changed or if they had less emotional breakdowns

References

Marzani, G., & Neff, A. P. (2021). Bipolar Disorders: Evaluation and Treatment. American Family Physician, 103(4), 227-239.

World Health Organization. (2020). Depression. Retrieved 28 March 2021 from https://www.who.int/news-room/fact-sheets/detail/depression