focused note

Week 3: (Mood disorder)

College of Nursing-PMHNP, Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Faculty Name

Assignment Due Date

Subjective:

CC (chief complaint): ‘I have history of taking medications and stopping them because thet squashes who I am’

HPI: P.P is a 25 years old female with history of bipolar and depression presented to the clinic for mental health assessment. Per patient report, patient has not been compliant with her medications because of the side effects she experienced from taking them which has led to the periods of hyperactivities, loss of sleep, anhedonia, impulsiveness, talkatiness and engaging in random sex with random individials. Patient reported her first episode and hospitalization was at the age of 16 and has had a total of 4 hospitalizations. Patient reported that she experiences depression about four times a year whePatient is in the office for possible medication changes.

Substance Current Use: Patient smokes a pack of cigarettes per day. Pt denies the use of other illicit drugs and Alcohol. The last time she had alcohol as reported by patient was at the age of 19.

Medical History:

· Current Medications: Levothyroxine ( dosage unknown) and birth control ( name and dosage unknown). Patient reported that prescribed Zoloft, risperidone and quetiapine in the past but she stopped taking them due to side effect and possible therapeutic effect which the patient was not comfortable with.

· Allergies: No known Allergies

· Reproductive Hx: Patient reported multiple sexual partners and engages in sex with random individual. Patient is oral contraceptives for polycystic ovaries. Never been married or pregnant. Last menstrual period was last month (date unknown).

ROS:

· GENERAL: No fever, chills, weakness, or fatigue and no weight loss

· · HEENT: Head is Normocephalic and atraumatic, Eye- pupils are equal, no discharges, No double, blurred vision. Ear, Nose, and Throat -No hearing loss, No congestion, no sore throat, and no sneezing

· · SKIN: Skin is warm, No rash or itching

· · CARDIOVASCULAR: No chest pain, No chest pressure, and no edema, No palpitation

· · RESPIRATORY: No respiratory distress.

· · GASTROINTESTINAL: No distension noted, No anorexia and vomiting

· · GENITOURINARY: No burning on urination

· · NEUROLOGICAL: The patient is alert and oriented, no dizziness, numbness, or tingling sensation of the extremities

· · MUSCULOSKELETAL: No muscle pain, No back pain, nobody stiffness, no edema noted

· · HEMATOLOGIC: The patient is not frail and no bleeding

· · LYMPHATICS: No enlarged lymph nodes.

· · ENDOCRINOLOGIC: No reports of polydipsia. Reported sweating and heat intolerance.

Objective:

Diagnostic results: An extensive psychiatry evaluation is needed to arrive at a diagnosis in most psychiatry conditions. The patient reported to be on an unknown medication for hypothyroidism, so a thyroid Panel wil be appropriate in this patient, according to Gaum et al. (2019), stated that If there is too little T4 in the brain, insufficient dopamine can be synthesized or released, leading to more depressive symptoms. Therefore thyroid panel.

Assessment:

Mental Status Examination: P.P is a 25 years old caucasioan female who looks older who looks her stated. The patient was alert and oriented. The patient was calm and cooperative all through the assessment. Patient is ambulatory, neatly groomed and clean. The patient was well coordinated; hence, no evidence of any abnormal motor activity. The patient was lucid, and the speech was clear, normal in volume and tone. Patient appears defensive and minizes symptoms at times. There was no sign paranoid behavior. Patient also demonstrated some form of grandiosity ( make up and sell painting to movie stars). Pt’s mood is euthymic and affect was appropriate to her mood. Patient reported that about 4 to 5 times a years, she experiences depressive symptoms of energy loss, lack motivation, worthlessness, disturbed sleep, anhedonia and hopelssness. The patient reported reported history of suicidal attempt where she overdosed with Benadryl about 3 years ago and history of auditory halluciantions ( telling her how great and talented sheis). Patient also reported periods where she experiences lots of energy, increased libido, talkatives and unkempet. That has also been hospitalized before for mnaic symptoms before ( dancing around on he field in her night gown with her guitar). The patient denies Visual and auditory hallucinations at this time and also denies suicidal ideations. The patient demonstrated fair insight and judgment to mental health needs. Patient’s memory (recent & remote) intact.

Diagnostic Impression: According to DSM-5, the patient showed signs and symptoms of Bipolar 1 disorder. According to Kaplan and Saddock (2015) stated that Bipolar disorder is a syndrome in which a complete set of mania symptoms occurs during the course of the disorder. The patient is in congruent with this diagnosis because she reported a period mania episode which are a period od elevated and expansive mood, increased energy, decreased need for sleep, more talkative than usual, mood disturbances necessitating admission and the episodes were not associated to drug/ substance abuse. Patient also reported symptoms depression which occurs after her manic and hypomanic episode like feelings of woorthlesness, sleep disturbance, depressed mood all day, anhedonia, hypersomnia, loss of energy, impairment of functioning ( loss of interest at work). Per DSM-5, the criteria for this diagnosis is at one manic episode in a lifetime.

Another possible diagnosis of this patient is Bipolar 11 Disorder. According to Kaplan and Saddock (2016), the clinical features of bipolar 11 disorder are those of a ajor depressive disorder combined with those of hypomania episode. Hypomania is a distinct period of abnormally and persistent elevated, expansive or irritable mood and abnormal persistently increased in energy. Hypomania episode episode is somewhat similar to manic episode but not intense to necessitate hospitalization. In this patient she was onces hospitalized due to full manic episode.

Reflections:

Case Formulation and Treatment Plan: 

References