week 4

Subjective:

CC (chief complaint): “I have a history of taking my medications and then stopping them, I don't think I need them, I really think that the medications squash who I am."

HPI: The patient, Petunia Park, is a 28-year-old Caucasian female who sought psychiatric evaluation following a chief complaint of diagnosis for not taking her previous medication because she believed the medication was suppressing her identity. She revealed her past four hospitalizations were linked to her mental health. She was first hospitalized when she was involuntarily committed by her mother because she could not sleep for several days. She sleeps 5 to hours daily, she gets about 3 hours of sleep per week when she’s creating and 12 -16 hours a day when she’s crashing. As a teenager, she was hospitalized after attempting suicide by overdosing on Benadryl, which was followed by auditory hallucinations. She was hospitalized again when she was found playing the guitar and dancing in a field wearing only a nightgown, but she believed her mother had fabricated this incident so she could live with her boyfriend. She had been diagnosed with depression, bipolar disorder, and anxiety, in the past. she stopped taking the medications that were prescribed for her for these symptoms due to side effects; Zoloft made her feel euphoric with her intense thoughts, which caused her sleep problems. Taking Risperdal and Seroquel caused unwanted weight gain. Klonopin slowed her down and that also made her stop using it. She experiences recurrent episodes that occur approximately 5 times per year. During this period, she exhibits a lack of energy, decreased motivation, a lack of interest in activities, and a feeling of worthlessness. She also describes periods when she experiences increased energy and creativity, becomes more talkative, experiences reduced need for sleep, and even exploring sexual activitities with different people just to keep her mood positive. The last episode which lasted for a week. She denies any current suicidal or homicidal ideation, even though but admits she had experienced previous auditory hallucinations. There are fluctuations in the diet, appetite decreases during creative periods, and increases when she’s crashing and resting.

Psychotherapy or previous psychiatric diagnosis: She had been diagnosed with depression, anxiety and bipolar disorder. She has had episodes of suicidal thoughts and auditory hallucinations in the past.

Substance Current Use: Smokes a pack of cigarettes daily. Tried cannabis in the past but stopped due to paranoia. Denies current use of alcohol but admits to taking alcohol when she was 19.

Family Psychiatric/Substance Use History: Mother had bipolar. Father went to Prison for drugs.

Medical History: She reports having hypothyroidism and polycystic ovaries.

1. Current Medications: Drugs for hypothyroidism and birth control pills for polycystic ovarian disease.

1. Allergies: No allerhies reported

1. Reproductive Hx: Denies getting pregnant or having children. Never been married. Has regular menstrual cycles. Had last menstrual period a month ago. She is in a relationship and uses birth control. Explores sex with different people to keep her mood high.

ROS:

1. GENERAL: No unintentional weight loss. Has a loss of appetite when she’s creating but increased appetite when crashing.

1. HEENT: No head injuries. No blurred vision. No hearing loss. No nasal discharge. No swallowing problems.

1. SKIN: No rashes. No bruises or injuries.

1. CARDIOVASCULAR: No chest pain. No palpitation No BP or pulse issues reported.

1. RESPIRATORY: No shortness of breath.No wheezing. Lungs are clear.

1. GASTROINTESTINAL: No abdominal pain reported. Nor nausea. No diarrhea. No vomiting.

1. GENITOURINARY: No change in urine colour reported. No painful urination. No UTIs

1. NEUROLOGICAL: No numbness. No coordination difficulties

1. MUSCULOSKELETAL: No muscle weakness or joint pain reported.

1. HEMATOLOGIC: No bruises or bleeding reported. No bleeding.

1. LYMPHATICS: No adnormal swelling. No splenectomy.

1. ENDOCRINOLOGIC: Hypothyrodism reported.

Objective:

Physical Examination: Temp 98.2 Pulse 90 Respiration 18 B/P 138/88

Diagnostic results: Urine drug and alcohol screen was negative. CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)

Assessment:

Mental Status Examination: The patient looked her stated age, clean, well-groomed, and appropriately dressed. She is fully oriented, attentive, cooperative, and friendly. Her mood matches her emotional expression. The tone and volume of her speech are mainly normal, but in some cases, she spoke in a high-pressure manner. She appears to be illogical in some of her thought processes and involves grandiose ideas that indicate delusional thinking. She reports anxiety, especially during the creative phase. She also mentions a lack of concentration, poor energy, excessive talkativeness, and multiple sexual partners sometimes. Currently, her memory is intact and there are no reports of visual or auditory hallucinations. She attempted suicide as a teenager but now denies having any suicidal or homicidal ideation.

Diagnostic Impression:

Bipolar I Disorder

Bipolar I disorder is a mental disorder diagnosed when a person experiences a manic episode. When a person with bipolar I disorder experiences a manic episode, their energy levels are so high that they may feel overwhelmed and uncomfortable. Some people with bipolar I disorder experience episodes of depression or hypomania (APA, 2021).

Using the DSM TR-5 criteria, bipolar I disorder diagnosis typically requires the presence of a 1-week epison of mania (APA, 2022). In this case, P. P. is diagnosed with bipolar disorder because he experiences week-long manic episodes during the creative phase. Mania includes symptoms such as elevated mood, decreased need for sleep, increased energy, talkativeness, as well as grandiose ideas.

Borderline Personality Disorder

Borderline personality disorder (BPD) is a common, treatable mental disorder, which affects people's thoughts, feelings, and behaviors, making it difficult to cope with all areas of life (Healthdirect, 2020). Symptoms of BPD are chronic frustration, limited independence, mood swings, lack of empathy, impulsivity, low self-esteem, and engaging in risky behavior among others. According to the DSM-5 criteria, to be diagnosed with borderline personality disorder, a person must exhibit a pattern of instability and have at least five of the outlined symptoms (APA, 2022). Among the listed symptoms of BPD, P. P. experiences unstable relationships, feels sad and unworthy, and engages in risky behavior but does not meet the minimum number of symptoms needed for a diagnosis of BPD.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is a psychological disorder that causes worry, fear, as well as making a person to constantly feel overwhelmed. Its characteristics include excessive, unrealistic, and persistent worries about everyday matters (Munir & Takov, 2022). Symptoms of GAD are fears, headaches, difficulty falling asleep, muscle tension, irritability, hot flashes, breathing difficulties, persistent nervousness, difficulty concentrating, being unable to relax, and being unable to control worries. According to the DSM TR-5, to be diagnosed with GAD, a person must experience excessive worry and have at least three symptoms for at least six months (Substance Abuse and Mental Health Services Administration, 2016). Although P. P. meets some of the criteria for GAD, bipolar I disorder better explains her manic symptoms.

Reflections: The case of P. P. further highlights the need for proper patient education. It also reiterates the importance of thorough treatment planning, legal and ethical considerations, socio-economic determinants of health, as well as health promotion. The patient's history of drug violations is an important point to note. Emphasis is placed on educating and involving patients in their treatment. Physicians and nurse practitioners must educate patients about the benefits, side effects, and alternatives of medications (De Baetselier et al., 2021). Proper patient education can improve adherence to medication and outcomes of treatment.

Case Formulation and Treatment Plan: 

The treatment approach for P. P.'s condition should be comprehensive; both pharmacological and nonpharmacological. mood stabilizers and antipsychotics will be prescribed for the patient. Risperidone is also an FDA-approved antipsychotic drug for treating bipolar disorder. Its antimanic antimanic activities will help stabilize P. P.'s mood.

Cognitive behavioral therapy (CBT) is also recommended to help her identify and combat maladaptive thoughts, improve her coping skills, and help her in effectively managing her emotions. She will initially be scheduled to come for regular psychiatric evaluations every 2 to 4 weeks to assess her response to treatment and effect any necessary adjustments to the dosage of her medication.

Alternative therapies for this patient include electroconvulsive therapy (ECT) to treat treatment-resistant symptoms or as an alternative therapy when drugs are poorly tolerated (Trifu et al., 2021). A follow-up arrangement will be planned to assess her response to treatment and implement any necessary changes to her treatment plan. Regular exercise, including walking, jogging, and dancing among others will be recommended to improve her overall well-being; this will improve her mood and reduce stress.

Also very important in P. P.'s treatment plan is patient education. She will be educated to understand her diagnosis, the importance of medication adherence, and the effects and side effects of treatment. To sustain the progress of P. P.'s care, appropriate resources, support groups, and family will play key roles in helping P. P. understand her care plan

References

American Psychiatric Association. (2021). What Are Bipolar Disorders? https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders, text revision DSM-5-TR. American Psychiatric Association.

De Baetselier, E., Dilles, T., Feyen, H., Haegdorens, F., Mortelmans, L., & Van Rompaey, B. (2021). Nurses’ responsibilities and tasks in pharmaceutical care: A scoping review. Nursing Open, 9(6). https://doi.org/10.1002/nop2.984

Healthdirect. (2020). Borderline personality disorder (BPD). https://www.healthdirect.gov.au/borderline-personality-disorder-bpd

Munir, S. & Takov, V. (2022). Generalized Anxiety Disorder. [Updated 2022 Oct 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/

Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.15, DSM-IV to DSM-5 Generalized Anxiety Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t15/

Trifu, S., Sevcenco, A., Stănescu, M., Drăgoi, A., & Cristea, M. (2021). Efficacy of electroconvulsive therapy as a potential first-choice treatment in treatment-resistant depression (Review). Experimental and Therapeutic Medicine, 22(5). https://doi.org/10.3892/etm.2021.10716