case

Mood Disorders in Adults

Week (#4): (Petunia Park)

Robin G Soto

College of Nursing-PMHNP, Walden Nursing

NRNP6665: PMHNP Across the Lifespan 1

Dr. Vardah Serphin

June 27, 2022

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Mood Disorders in Adults

Petunia Park

Subjective:

Chief Complaint: Mental Health Assessment

History of Present Illness (HPI.): Ms. P.P appears to be a young Mexican woman, age

19, present for mental health assessment. Ms. Park stated her birth date is July 1, 1995. She has no current

medication presently. She has a history of taking drugs and then stopping them. Ms. Park stated, “I

don’t think I need them. I feel like the medication squash who I am”. The patient continues to have

anxiety, depression, and manic episodes, with possible OCD and schizophrenia due to hearing voices and

hospitalization. P.P. works at aunt bookstore once in a while. The patient stated she is in Voc-tech school

for cosmetology. “I am going to do make-up for movie stars.

General Statement: I will get enough information to come up with a treatment plan and maybe

find some medications that will make you feel better without you feeling so squashed and having negative

side- effects, but help you able to function through the day.

Caregiver: Ms. P is her caretaker but lives with her boyfriend; but sometimes stays with

mom and brother when he gets mad for becoming and being promiscuous.

Hospitalization: Ms. Park stated: “When I was a teenager, my mother put me in the hospital

after I went four or five days without sleeping. I think I may have been hearing things at that time”.

[Chuckles]. Ms. Park stated she had been confined to hospitalization about four times. The last time was

this past spring. No detox or residual rehab, though. One was in 2017. I overdosed on Benadryl, but I

have not had those thoughts. Police picked her up and took her to the hospital once.

Medication trials: Ms. Park has taken Zoloft, which made her feel high and could not sleep,

Risperidone, which made were mind race and gained a bunch of weight, Seroquel has increased

importance as well, and Klonopin, which seemed to slow her down. I really cannot remember the others.

“I think the one I just stopped helping.” It started with an “L,” I think. I do not reflect the name, but it

squashed me in creativity.

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Mood Disorders in Adults

Psychotherapy or Previous Psychiatric Diagnosis: Ms. Park stated depression, anxiety, and

some bipolar and denies OCD. Not hearing or seeing thing right now (schizophrenia). Sometimes when I

am not sleeping well, I listen to the voices telling me how great and wonderfully talented I am. It has been

a couple of months since that happen.

Substance Current Use and History: Smokes about a pack a day, not going to quit for you

either. Ms. P. drank alcohol at age 19, but it did not work well with me. Ms. Park denies using

marijuana, cocaine, stimulants or methamphetamines, or any huffing or inhalant. Dismiss any sedative

mediations such as Klonopin or Xanax, hallucinogenics like LSD, PCP, or mushrooms. Ms. P. does not

use pain pills, or opiate medications, or anything prescribed or from the streets. Dismiss any synthetic like

spice, ecstasy, Bath Salts, Mollies. Ms. Park denies any seizures or blackouts from drugs or alcohol use.

Family Psychiatric/Substance Use History: The mother perceives to be crazy. I think she had

bipolar or something? My father went to prison for drugs, and I have not heard or seen from him since in

eight or ten years. My brother, I think, is a little “schizo,” but he has never seen a doctor. My mother

attempted to commit suicide. Ms. Park tried to cut herself and kill herself. There was abuse by their

father, and him being hard on her, yelling a lot. Ms Park denied any sexual abuse or physical abuse.

There was emotional and possible mental abuse in the yelling and her behavior.

Medical History: Ms. Park states she has thyroid issues and polycystic ovaries, loves sex, and

loves to explore sex with different men.

Current Medications: None. Ms. P had tried several medications; her recent history of taking

and then stopping them is a reliving problem. Ms. P. is on birth control pills for polycystic ovaries. Her

medications were Zoloft, which made her feel high, she could not sleep, and her mind was racing;

Risperidone, gained much weight; Seroquel gained weight also. Klonopin: that seems to slow me down.

The last one begins with an “L.” I do not remember, but that squashes me in creativity.

Allergies: No allergies stated to medication, food, or pollen.

Reproductive History: On birth control pills, denies being pregnant. Have regular menus. Being

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Mood Disorders in Adults

promiscuous, but declares being safe. Menses was last month sometime and would not give a specific

date. Ms. P.P. identifies herself as a woman. Ms. P. states she has polycystic ovaries.

R.O.S.

General: The patient appears in good health, is height/ weight proportionate, she appears slightly

older than she stated. Vital signs typical, no fever. No malaise or weight

HEENT: No blurred vision, visual loss, or yellow sclera. Ears, Nose, Throat: No hearing loss,

nasal drainage/congestions, headaches, or sore throat.

SKIN: No wounds, flushing, rashes, redness, or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, difficulty breathing, cough, sputum, or cyanosis

GASTROINTESTINAL: No anorexia, nausea, vomiting, diarrhea, or constipation. No

abdominal pain or discomfort. No blood.

GENITOURINARY: No burning on urination, urgency, hesitancy, pain, or discomfort. Denies

any odor or odd color in urine. No alteration in the bladder.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in

the extremities. No change in bowel or bladder control. The gate appears even and smooth.

MUSCULOSKELETAL: No muscle or joint pain, weakness, back pain, stiffness, or reduction

of range of motion.

HEMATOLOGIC: No excessive bleeding, anemia, clotting, or bruising.

LYMPHATICS: No enlarged painful nodes. No history of splenectomy

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance, hair loss, excess

urination, fatigue, or polydipsia. She has thyroid issues.

OBJECTIVE:

Diagnostic results: Vital signs are within normal range: Temp: 98.2; Pulse: 90: Respiration: 18:

Blood Pressure: 138/88. Laboratory Test: Urine drug and alcohol screen negative. CBC within normal

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Mood Disorders in Adults

ranges, CMP within normal ranges. Lipid panels are within normal ranges. Prolactin Levels 8; TSH 6.3

(H). The CMP and CBC can help determine the general health of the patient. Still, TSH and PRL are

necessary due to the relationship between reproductive hormones, thyroid disease, and depression in

women. The prolactin is normal but on the low side. Hypothyroidism and medication can create Hypo-

prolactinoma levels (Jacobson, 2012; Petruzzelli et al., 2020). TSH levels can cause an increased risk for

readmission secondary to exacerbated depressive symptoms when thyroid disease is untreated (Yang et

al., 2021).

Assessment:

Mental Status Examination:

The patient appears alert but not orientated. Ms. P. stated her birthday is July 1, 1995, and today’s

date patient said December 1st, 2020, which makes her only five years old. Ms. P’s developmental age

appears a lot older than that. She seems to be about 19 years of age, a Mexican American young woman

who looks much older than her age. She is semi-cooperative. She is neatly groomed and clean and dressed

appropriately. There is no evidence of any abnormal motor activity. Her speech is clear, presently

coherent during the interview, and standard in volume and tone. The thought process is incongruent with

her goals directed and logic. Her logic was fair to poor, and insight was noted. Documented delusional

thought process and pattern, but no AVH during the time of interview. Her mood is euphoric, and her

affect appropriate to her spirit. There is some evidence of loss of association or flight of ideas. The

patient’s eye contact is good; the patient’s body position is closed, with legs crossed in the chair.

Presently patient denies thoughts of suicide/self s harming but had thought in the past. She was chucking

at inappropriate times. She denies any auditory or visual hallucinations at this time. Cognitively, she is

alert and oriented. Her recent and remote memory is semi-intact all the way. She could not remember the

drugs, dosage, and last time taken. Her hospitalization was unknown dates, where, and when or durations.

Her concentration appears fair. Her insight is acceptable to the poor. She smokes and drinks, and she is

highly promiscuous.

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Mood Disorders in Adults

Diagnostic Impression:

The patient has multiple diagnoses. She does not meet all the criteria for Schizoaffective.

According to American Psychiatric Association (2013), schizoaffective disorder is based on assessing an

uninterrupted period of illness during which the individual continues to display active or residual

symptoms of psychotic illness such as schizophrenia. She hears the voices when she is manic, and lacks

sleep. There are some overlapping symptoms, but she does not meet all criteria (Baryshnikov et al.,

2020). She may meet the criteria for Bipolar Disorder with a introductory presentation of mania and

depression (American Psychiatric Association, 2013). Manic has inflated self-esteem, decreased need for

sleep, and flights of the idea. MDD is depression most of the day, insomnia, fatigue, feeling of

worthlessness, or excessive or inappropriate guilt (Chen et al., 2021; Sadock et al., 2015). The third

possible diagnosis is a personality disorder. Diagnosis of borderline personality. It is a pattern of

instability in interpersonal relationships, self-image and affects, and marked impulsivity (American

Psychiatric Association, 2013; Bateman et al., 2015). She does meet these criteria because of the sexual

risky behavior, instability interpersonal relationships, unstable self-image, self-cutting, and suicide

attempts. This diagnosis will be deferred until it is collected and until other diagnoses are explored

(Choukas-Bradley et al., 2020; Bateman et al., 2015).

Reflection:

In reflection on this case in question, questions regarding the extent, nature and frequency of her

sexual risky behavior, suicide attempts, mania and depression . The trauma that occurred during her

childhood needs to be further study and how it affected her. The information must differentiate between

bipolar and personality disorder fully. Currently the behavior could point to personality disorder,

specifically borderline personality, with a possible dual diagnosis of bipolar. The hearing of voices comes

when she’s manic and lack of sleep, which fits the diagnosis of bipolar. I do not think the schizoaffective

disorder is the appropriate diagnosis. Medication is not first-line treatment, if she has borderline

personality disorder. Psychosocial intervention is the primary treatment (Bateman et al., 2015). With

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Mood Disorders in Adults

comorbidity as in this case, Bipolar, medication would help and could be treated .

Case Formation and Treatment Plan

This Ms. P. tried so many medications and she has as a history of taking drugs and then stopping

them; also, she has thyroid disease. My most significant concern is her risky behavior, mania, suicide

attempts, and depression. Order labs and EKG to monitor the OT intervals, daily weight, Rapid plasma

regains (RPR) and genetic marker for the family. I would like to see a PCP to start her on Synthroid, plus

considered Topiramate 50 mg B.I.D for mood and sleep (Stahl, 2017; Kantojarvi et al., 2020). Will

slowly titrated medication up while assessing for side effects and efficacy over the next several months in

an outpatient setting. The following medication would be Citalopram 20mg daily, which is a SSRI and S-

RI, would use this for mood stabilization (Stahl, 2017; Onishi et al., 202; Kantojarvi et al., 2020). Will be

slowly titrated up medication while assessing for side effects and efficacy over the next several months.

I would start therapy to explore the nature of her risky sexual behavior, her ineffective coping

mechanism, and her instability interpersonal relationships. She will need support in identifying cognitive

distortions, addressing stuck points in her trauma, creating a safety plan, and identifying positive coping

skills. Ms. P. will have appointments for therapy and psychiatry services.

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Mood Disorders in Adults

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American

Psychiatric Association.

Baryshnikov, I., Sund, R., Marttunen, M., Svirskis, T., Partonen, T., Pirkola, S., & Isometsä, E. T. (2020). Diagnostic

conversion from unipolar depression to bipolar disorder, schizophrenia, or schizoaffective disorder: A nationwide

prospective 15‐year register study on 43 495 inpatients. Bipolar Disorders. https://doi.org/10.1111/bdi.12929

Bateman, A. W., Gunderson, J., & Mulder, R. (2015). Treatment of personality disorder. The Lancet, 385(9969), 735–743.

https://doi.org/10.1016/s0140-6736(14)61394-5

Case Study: Petunia Park. (2021). https://class.waldenu.edu. Walden University Blackboard:

Chen, H., Li, W., Cao, X., Liu, P., Liu, J., Chen, X., Luo, C., Liang, X., Guo, H., Zhong, S., Wang, X., & Zhou, J. (2021).

The Association Between Suicide Attempts, Anxiety, and Childhood Maltreatment Among Adolescents and Young

Adults With First Depressive Episodes. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.745470

Choukas-Bradley, S., Hipwell, A. E., Roberts, S. R., Maheux, A. J., & Stepp, S. D. (2020). Developmental Trajectories of

Adolescent Girls’ Borderline Personality Symptoms and Sexual Risk Behaviors. Journal of Abnormal Child

Psychology, 48(12), 1649–1658. https://doi.org/10.1007/s10802-020-00699-4

CrashCourse. (2014). Depressive and Bipolar Disorders: Crash Course Psychology #30. On YouTube.

https://www.youtube.com/watch?v=ZwMlHkWKDwM

Jacobson, S. A., & American Psychiatric Publishing. (2012). Laboratory medicine in psychiatry and behavioral science.

American Psychiatric Pub.

Kantojärvi, L., Hakko, H., Mukka, M., Käyhkö, A., Riipinen, P., & Riala, K. (2020). Psychotropic medication use among

personality disordered young adults. A follow-up study among former adolescent psychiatric inpatients. Psychiatry

Research, 293, 113449. https://doi.org/10.1016/j.psychres.2020.113449

Onishi, Y., Mikami, K., Kimoto, K., Watanabe, N., Takahashi, Y., Akama, F., Yamamoto, K., & Matsumoto, H. (2021).

Second-Generation Antipsychotic Drugs for Children and Adolescents. Journal of Nippon Medical School, 88(1),

10–16. https://doi.org/10.1272/jnms.jnms.2021_88-108

Petruzzelli, M. G., Marzulli, L., Giannico, O. V., Furente, F., Margari, M., Matera, E., & Margari, F. (2020). Glucose

Metabolism, Thyroid Function, and Prolactin Level in Adolescent Patients With First Episode of Schizophrenia and

Affective Disorders. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00775

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical

psychiatry (11th ed.). Wolters Kluwer.

Stahl, S.M. (2017). Essential Psychopharmacology: Prescriber’s Guide (6th.). University Printing House

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Mood Disorders in Adults

Yang, L., Yang, X., Yang, T., Wu, X., Sun, P., Zhu, Y., Su, Y., Gu, W., Qiu, H., Wang, J., Chen, J., & Fang, Y. (2021). The

effect of thyroid function on the risk of psychiatric readmission after hospitalization for major depressive

disorder. Psychiatry Research, 305, 114205. https://doi.org/10.1016/j.psychres.2021.114205

Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing.

Walden University.(2022). Minneapolis, Minnesota

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