• NRNP 6665: PMHNP Week 4 Assignment

Student Name

University

NRNP 6665: PMHNP

Professor Name

Submission Date

Assessing, Diagnosing, and Treating Adults with Mood Disorders

Student Name

Name University

NRNP 6665: PMHNP Care across the Lifespan I

Dr. / Prof Name

Submission Date 

Subjective:

CC: “I am here because I have been starting and stopping my medication, and it feels like it’s crushing my creativity and my essence of who I am. I want to get help finding a medication that I can take that doesn’t make me lose myself.”

HPI:

The patient, Petunia Park, a 25-year-old White female, presents for follow-up as she continues to experience problems with mood instability and medication management. She has a history of extreme mood changes with episodes of manic-like mood and increased energy for about a week, and then severe episodes of depression for about the same period of time. Some mood changes have been seen for a few years now, and the most recent depressive state has happened haphazardly during the past couple of months. During her bouts of depression, Petunia finds herself feeling unworthy, lethargic, and sleeping a lot (12-16 hours a day).

She experiences a worsening of her symptoms since her last visit, and now has more and more severe manic and depressive episodes. Exacerbating factors for Petunia are stressors associated with her creative endeavors and relationships. She has complained that some drug trials have had negative side effects, including getting poor night’s rest, putting on weight, and being “squashed emotionally. These issues have prevented her from following her treatments, which has resulted in her symptoms coming back. She rates the level of mental pain on a scale of 1-10, a very high 9/10.

Substance Current Use:

According to Petunia Park, people are currently using nicotine, and they smoke about 1 pack of cigarettes each day. She adamantly states her refusal to quit smoking. She has never used drugs (marijuana, cocaine, stimulants, hallucinogens) or other illegal substances and has not used any recently. At age 19, Petunia discontinued her drinking because of the negative effects. There is no history of inhalant, IV, or other non-oral drug use. She has no history of withdrawal symptoms, including tremors, Delirium Tremors,s or seizures caused by substance use. In general, her substance use has been more limited to regular nicotine use, and she has not used alcohol or avoided use of other illegal substances.

Medical History:

Current Medications:

• She doesn’t specify the dosage or frequency of Zoloft (Sertraline), and she discontinued it because of severe insomnia and racing thoughts.
  • Risperidone- dosage and frequency not specified; stopped when significant weight gain was observed
  • Seroquel (Quetiapine)- dosage and frequency unknown/ not specified; discontinued because of weight gain
  • Klonopin (Clonazepam)- dosage and recurrence not specified/ mentioned; it “slowed her down” so no longer in use
• An unidentified drug that began with the letter “L” was effective, but I stopped using the drug because of a reported loss of creativity

Treatment was not reported to be using any OTC or herbal medications.

Allergies: States that he or she does not have a known allergy to any type of medication. She has no known food allergies, sensitivities or adverse reactions to food. No documented allergy symptoms from an environmental source ( pollen, dust, animal dander) that result in allergic rhinitis or asthma. Petunia has not had any episodes of angioedema, anaphylaxis or other severe medication, food, or environmental allergy. She also doesn’t have any chemical sensitivity to chemicals or chemical products, such as latex, plastics, rubbers, gases,s etc.

Reproductive Hx:

• Menstrual history: Reports regular menstrual cycles, and her LMP was last month. No irregularities in the menstrual cycles, monthly.
• Married: Never been married/never had a spouse
• Q Nursing/Lactating: No longer nursing/lactating
• Contraceptive use: Birth control pill users for PCOS (no indication of which pill); does not specify what type of birth control pill she is taking
• Sexual intercourse: Has sexual intercourse with the vagina. Discusses sexual activity as a way to raise the level of feeling better
• Sexual concerns (does not report or express any sexual concerns)

ROS:

• GENERAL: Rejects weight gain or loss, fevers, chills, or excessive tiredness beyond that of her mood symptoms.
• SKIN: Rejects any rashes, itching, lesions, or changes in skin color.

CARDIOVASCULAR: Rejects chest pain, palpitation,s or swelling in the legs.

RESPIRATORY: Rejects any difficulty with breathing, cough, hoarseness, or wheezing. No mucous or sputum secretion.

GASTROINTESTINAL: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. No reports of “eating disorders” of any kind, such as anorexia or bulimia.

• Does NOT report dysuria, frequency, urgency, hematuria, or any lesions of the genitalia.
• Neurological: Reports no seizures, weakness, sensory loss,s or any coordination problems.

MUSCULOSKELETAL: Reports no pain, stiffness, swelling, ng or restriction of motion.

HEMATOLOGIC: No history of bleeding tendencies, easy bruising, or anemia reported

LYMPHATICS: Denies any swollen lymph nodes or recurrent infections.

• Para medically, Petunia has hypothyroidism and takes medication for it. She does not have any symptoms of polyuria, polydipsia, heat or cold intolerance, or any changes in appetite associated with her thyroid condition.

Objective:

Diagnostic results:

Thyroid Function Tests (TSH, T3, T4), Complete Blood Count (CBC), Blood Metabolic Panel (BMP), Liver Function Tests (LFTs), Urinalysis. A psychiatric assessment and a review of the medications’ history.

Assessment:

Mental Status Examination:

Petunia Park is a clean, well-groomed, well-dressed Caucasian female, 25 years old. She is socially normal, has good eye contact, and body posture, which will enable them to talk to her. Throughout the evaluation, she has some animated phrases in response to questions regarding her future plans in the area of cosmetology/art, but she can be very reserved. However, she can become sad and frustrated and changes her mood if she speaks about medications and/or having been hospitalized. She is not very assertive regarding her mood and follows it up with rational answers to various situations, which places her in the normal range. There is no disturbance in the fluency of speech, and Petunia speaks in a relatively grammatical manne,r with her rate of speech sometimes increasing during the affective episodes.

Knowing all this, she outright denies any current plans to harm herself or others, saying that she is disgusted by the idea, which wasn’t part of her world until she attempted suicide in 2017. When considering Petunia’s thinking, there are no signs of racing thoughts; Petunia’s decision-making is logical and sensible. Reality, she says, is that she does not suffer from hallucinations and delusions at this time, and previous perceptual differences aren’t due to sleep deprivation. But her ability to think appears relatively intact, as she can plan for her future in work and abstractly reason. Petunia appreciates the need for treatment, but she has some issues with it because of previous unsuccessful treatments. Her decision-making capability does not seem impaired in unaltered conditions, as evidenced by her attending employment and education in accordance with changes in her moods. It is recommended that she keep trying it and keep changing it until she becomes happier and calmer due to her temper.

Diagnostic Impression:

Based on the comprehensive assessment of Petunia Park, the best and presumptive diagnostic impression is Bipolar II Disorder (ICD-10 code: F31. 81). This could be supported by her history of filling in the Witch’s calendar, which indicates that she meets the diagnosis criteria of Bipolar II Disorder (Kessing et al., 2021) (recurrent and alternating hypomanic and depressive periods). Petunia reports hypo-mania experiences every about a week in which she feels more energetic, sleeps less, and is more creative. These are followed by episodes of depression of the retarded type in which one can feel tired, apatheti,c and unworthy.

The three differentials for her selection are:

1. Bipolar II Disorder (ICD-10: F31.81)
2. Major Depressive Disorder (ICD-10: F32)
3. Bipolar I Disorder (ICD-10: F31.9)

Rationale:

The clinical features of Petunia meet the criteria for bipolar II disorder (at least one hypomanic episode and one major depressive episode). She has a history of hyperactive mood with hypomanic features: flighty, needing less sleep. In between these episodes, she is not so impaired and is able to go to work or school during periods of stability, which is consistent with the severity of the episodes.

Diagnoses Ruled Out:

Hypomanic episodes, which are not typical of MDD but common in Bipolar II Disorder (Beglyankin et al., 2019), were used to exclude MDD from Petunia’s diagnosis. The history of Petunia more reflects the milder hypomanic episodes that are characteristic of Bipolar II Disorder (ICD-10 Code: F31.9) than more severe manic episodes, as would be typical in Bipolar I Disorder. She does not have full manic episodes or psychotic symptoms, which do not meet the criteria for bipolar I disorder.

Pertinent Positives:

Petunia Park presents with several pertinent positives indicative of Bipolar II Disorder. She reports recurrent episodes of elevated mood for about one week, which are associated with increased energy and reduced need for sleep. During these hypomanic periods, there is increased creativity and self-confidence. Petunia has been active and productive, doing so with enthusiasm during these times, in the sense of engaging in goal-directed activities. These episodes are alternated by depressive episodes during which people lack energy, interest in activities they used to enjoy, and feel unworthy. The descriptions of these mood swings fit the DSM-5 criteria for Bipolar II Disorder, and are consistent with the symptoms described by Petunia.

Pertinent Negatives:

She does not report any full-blown manic episodes, which involve significant disturbance in social or occupational functioning or hospitalization. At the time of her evaluations, she is not exhibiting any signs of psychosis (hallucinations or delusions). Despite her mood swings, Petunia also denies current suicidal or homicidal thoughts, suggesting a relatively stable mood state. These relevant negatives help to exclude Bipolar I Disorder and Major Depressive Disorder, which are more severe disorders.

Reflections:

I think the diagnostic impression of the authors for Petunia Park is generally correct, and the ICD-10 code F31 – Bipolar II Disorder. 81) of my preceptor. It can, therefore, be concluded that Petunia meets the criteria for Bipolar II disorder given in the DSM-5 because she has had multiple hypomanic and depressive episodes. She has this type of mood disorder as she loses interest in activities, energy, and sleep during the cycling phases of moderate mood, high energy, and reduced sleep requirements, while experiencing low mood, low energy, and reduced interest in activities during the episodes of low mood. Without evidence of full-blown manic episodes and/or psychotic symptoms, it may be difficult to rule out Bipolar I Disorder.

This case has brought into focus the need to establish psychiatric history and, more so, a detailed one that focuses on mood changes and symptoms. It has also highlighted the problem of adherence to medication and the effect that patients’ previous experiences can have on their involvement in drug therapy. I would spend more time in the future on the repetitive evaluation of Petunia’s mood state stability, and how she reacts to medications, groups, and psychotherapy for Bipolar II Disorder, giving her a better understanding of the illness.

From a legal and ethical perspective, it is pertinent to go beyond the concepts of confidentiality and consent. When it comes to treatment options, informed consent is important, particularly regarding Petunia, who is willing to take medications as a result of bad experiences in the past ( Xu et al., 2020). So there can be implications concerning individuals’ socioeconomic status and cultural background on how they will receive treatment whenever they fall ill. Individual interventions should thus be integrated into the prevention procedures to increase patients’ awareness and ability to control chronic conditions such as Bipolar II Disorder.

Case Formulation & Treatment Plan:

Diagnostic Formulation:

Recurrent hypomanic episodes, with heightened energy, reduced sleep requirement, and mood swings between hypomanic and depressive episodes, with low mood, reduced interest, and fatigue during the latter, support this diagnosis.

Diagnostic Studies and Referrals:

Laboratory Studies: Baseline metabolic panel (BMP) with electrolytes, renal function tests (RFTs), liver function tests (LFTs), complete blood count (CBC) and thyroid function tests (TFTs) are ordered to evaluate baseline health status and metabolic parameters before starting pharmacotherapy.

Referrals: Referral to a psychiatrist for a more complete evaluation, formulation of a comprehensive treatment plan and ongoing management of Bipolar II Disorder.

Therapeutic Interventions:

Psychoeducation: Providing Petunia and her family with education about Bipolar II Disorder, including recognizing symptoms, triggers, and the necessity of adhering to treatment to reach a stable mood and prevent relapse.

Psychopharmacology:

Mood Stabilizer (Lamotrigine):

Starting dose: 25 mg once daily for 2 weeks.

Titration: Up to 25 mg per week until the desired maintenance dose of 100 – 200 mg/day is achieved, depending on clinical response and tolerability.

Monitoring: Every week for the first month and then every two weeks until the dose is adjusted and as needed to look for possible side effects, like a rash or dizziness.

Adjunctive Medication for Sleep (Trazodone):

Used as necessary for sleep disturbances in depression.

Initial dose: 25-50 mg orally at night, to be adjusted according to efficacy and tolerability.

Education:

Petunia will be provided with comprehensive consultations about the value of the medicines she is prescribed and the possible risks they pose to her. Specifically, she will be informed of the common side effects of Lamotrigine (dizziness) and the relatively rare but very serious side effect of a rash that requires immediate medical attention (Edinoff et al., 2021).

Disposition and Follow-Up:

Petunia will see a licensed therapist who specializes in Cognitive Behavioral Therapy (CBT) for Bipolar Disorder for disposition. In this therapeutic approach, mood stability and stress management skills will be improved, and strategies for relapse prevention will be developed. Follow-up visits with the psychiatrist will help track how well the medication is working, manage any side effects that develop, and fine-tune the treatment for further improvement. In addition, regular contact with her primary care provider (PCP) will provide her with complete health monitoring, which will include metabolic panel and thyroid function tests every 3 months initially, then every 6 months after that when she is stable.

References

Beglyankin, N. I., Burygina, L. A., Levin, M. E., & Bardenshteyn, L. M. (2019). Features of depressive episode with onset in adolescence and the risk of developing bipolar depression. Neuroscience and Behavioral Physiology, 50(1), 35–39. https://doi.org/10.1007/s11055-019-00865-2

Edinoff, A. N., Nguyen, L. H., Fitz-Gerald, M. J., Crane, E., Lewis, K., Pierre, S. S., Kaye, A. D., Kaye, A. M., Kaye, J. S., Kaye, R. J., Gennuso, S. A., Varrassi, G., Viswanath, O., & Urits, I. (2021). Lamotrigine and Stevens-Johnson syndrome prevention. Psychopharmacology Bulletin, 51(2), 96–114. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8146560/

Kessing, L. V., González-Pinto, A., Fagiolini, A., Bechdolf, A., Reif, A., Yildiz, A., Etain, B., Henry, C., Severus, E., Reininghaus, E. Z., Morken, G., Goodwin, G. M., Scott, J., Geddes, J. R., Rietschel, M., Landén, M., Manchia, M., Bauer, M., Martinez-Cengotitabengoa, M., & Andreassen, O. A. (2021). European Neuropsychopharmacology, 47(47). https://doi.org/10.1016/j.euroneuro.2021.01.097

Xu, A., Baysari, M. T., Stocker, S. L., Leow, L. J., Day, R. O., & Carland, J. E. (2020). BMC Medical Ethics, 21(1). https://link.springer.com/article/10.1186/s12910-020-00538-7