PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
PRAC 6635 Wk 9 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
CC (chief complaint):”medication refill”
HPI
DM is a 30-year-old AA female who has come to the clinic for medication refill. Patient reports that she has hx of paranoia and anxiety which led to her being admitted to the hospital about a year ago. Patient reports she was diagnosed with Bipolar II depressive type at the age of 19. After the discharge from hospital patient has been on the same medications as reports on her medication list. Patient states that her medications has been filled previously in a community clinicbut they refused to refill her medications as she had missed several visits and had not seen the Doctor for a long time due to the pandemic.
Patient reports she has mood swings frequently which have been well controlled with med
PRAC 6635 Wk 9 Assignment 2 Comprehensive Psychiatric Evaluation and Patient Case Presentation
ication and coping skills. Patient states that she has difficulty concentrating at times and finishing tasks and her mind is racing a lot of times. Patient reports she has a full time job but she does not feel fulfilled as she has suffered a lot of losses in the past year and has not been in a relationship or been intimate with anyone since 2019.
Patient states that she is starting to get nervous and stressed because she does not want to be out of medications and end up in hospital again. Patient reports she does not have a lot of support system and mostly keeps to her self. Patient acknowledges that she build up things and does not express her feelings freely.
Patient does not report hallucinations, delusions, obsessions, or compulsions. Patient’s activity level, attention and concentration were observed to be within normal limits. Patient does not report symptoms of eating disorder. There is no recent weight loss or gain.
Patient currently denies suicidal ideation ( had hx of suicidal attempt when pt was 13 yo), denies SIBx, denies homicidal ideation, denies violent behavior, denies inappropriate/illegal behaviors.
Past Psychiatric History: Previous psychiatric diagnoses: Bipolar disorder II depressive type ( at age 19 years old). Patient was on the reported meds for the past years.
- General Statement: 30 year old AA female here for medication refill.
- Caregivers (if applicable): No caregivers
- Hospitalizations: Manic episode- last admission was 2020 at PIW
- Medication trials: haldol, seroquel, carbamazepin
- Psychotherapy or Previous Psychiatric Diagnosis : Bipolar disorder II depressive type ( at age 19 years old). Pt was on the reproted meds for the past years.
Substance Current Use and History: Client denies use or dependence on nicotine/tobacco products.
PRAC 6635 Wk 9 Assignment 2 Comprehensive Psychiatric Evaluation and Patient Case Presentation
Client does not report abuse of or dependence on ETOH, and other illicit drugs.
Family Psychiatric/Substance Use History: Bipolar from father side, no mental health from mother side. Pt is the only child. No reported knowledge of family history of substance use issues.
Psychosocial History: Occupational History: Patient is a 30 year old AA female, single, lives alone and has no social life. She is currently employed and denies military service.
Education history: started college, did not finish
Developmental History: no significant details reported.
Legal History: pt had hx of arrested but never convicted
Spiritual/Cultural Considerations: none reported.
Medical History:
- Current Medications:
- Benztropine 1 mg tablet every day by oral route at bedtime.
- Oxcarbazepine 300 mg1 tablet twice a day by oral route with meals
- Risperdal 2 mg tablet 1 tablet every day by oral route
- Allergies: Peanut
- Reproductive Hx: Menarche at 12years, regular peiods, no children
ROS:
- GENERAL: Anxious female, looks older than stated age, seeking medication refill
- HEENT: Eyes: no irritation or dry eyes.Ears: no difficulty hearing or ear pain. Mouth/Throat: no sore throat or dry mouth.
- SKIN: Skin: no jaundice, rashes, laceration, or abnormal mole
- CARDIOVASCULAR: Cardiovascular: no shortness of breath when walking or breath when lying down and no palpitations or chest pain.
- RESPIRATORY: Respiratory: no cough, wheezing, shortness of breath, or coughing up blood.
- GASTROINTESTINAL: no nausea, vomiting, constipation, diarrhea, dyspepsia, or abdominal pain and normal appetite
- GENITOURINARY: Genitourinary: no incontinence or difficulty urinating
- NEUROLOGICAL: : no weakness or loss of consciousness
- MUSCULOSKELETAL: Musculoskeletal: no muscle aches or weakness and no back pain or swelling in the extremities
- HEMATOLOGIC: : No bruises, bleeding, or anemia.
- LYMPHATICS: has no history of splenectomy and has no swollen lymph nodes
- ENDOCRINOLOGIC: : has no abnormal sweating or excessive thirst
Physical exam: if applicable
Diagnostic results:
| GAD-7 | Not scored | |
| PHQ-2/PHQ-9 | 5 (for the PHQ-9) | |
| MDHAQ | Not scored |
Assessment
Mental Status Examination:
Appearance: well-groomed, clean, and normal weight. Behavior: calm, pleasant, eye contact, and guarded. Speech: fluent, clear, and soft. Perception: no hallucinations. Cognition: oriented to situation, time, place, and person and alert and memory intact. Intelligence: average . Memory: remote and recent. Mood: euthymic. Affect: anxious and flat and euphoric and congruent to thought content. Insight: intact. Judgment: intact. Thought Processes: intact. Thought Content: unremarkable. Motor Activity: intact.
Differential Diagnoses:
Bipolar II disorder
This patient has a history of previous hospitalization where a diagnosis of bipolar II(depressive type), was made. For a diagnosis of Bipolar II, the DSM-5 (2013) states it is characterized by at least one hypomanic episode and one or more major depressive episodes.
Patient has a history of attempted suicide at the age of 13, indicating a depressive episode and a family history of Bipolar disorder. According to O’Donovan, C. et al; (2020), of people presenting with an episode of major depression, a certain proportion may in reality be suffering from depression that is of bipolar type.
This could be for several reasons: in many if not most cases bipolar disorder starts with symptoms of depression and first hypomania/mania may not appear until years later; depression is considered a part of the bipolar genetic spectrum and thus some forms of depression are conceivably variants of bipolar disorder, particularly in those with a strong family history
Major Depressive Disorder
Studies have shown there are distinct biomarkers that distinguish unipolar depression frommthe depressive state in Bipolar disorder. Menezes, I. et al; (2019) report that
Clinical studies have shown about 40%–50% of BPD patients are firstly erroneously diagnosed with MDD and the correct diagnosis use to be delayed about 8-10 years
BPD is characterized by recurrent episodes of depression and elevation of mood (mania and/or hypomania), being in a depressive state more frequent, longer and disabling than hypo/manic state in BPD .
Bipolar patients are more likely to have a family history of BPD, greater number of affective episodes, psychiatric hospitalization, suicide attempts, and earlier onset of the disease than unipolar depressed patients. This patient was first diagnosed at 19, attempted suicide at 13, and has a family history of Bipolar disorder, making Bipolar II disorder my first choice as a differential diagnosis.
Attention Deficit Hyperactivity Disorder (ADHD)
Patient reports that her mind in constantly racing and she has difficulty concentrating and finishing tasks. Pinna, M. et al; (2019) state the symptomatology of BD and ADHD can overlap, with mood instability, distractibility, bursts of energy and restlessness, talkativeness, racing thoughts, impulsivity, impatience, impaired judgment, and irritability found in both disorders
While this is not my first choice, I believe more indepth interview may need to be carried out as patient may have ADHD as a comorbid condition with Bipolar disorder.
Reflections
In the course of doing this assignment, I came to realize how important it is for a mental health clinician especially, to thoroughly assess their clients, and to rule out substance abuse dependence and medical conditions that may present as psychiatric disorders, prior to making their diagnosis as even abnormalities of the immune system, including thyroid dysfunction, might be a potential factor contributing to the development of these mental disorders (Jucevičiūtė, N.et al; 2019).
Important legal documentation prior to treating patients was also evident in this case presentartion as patient had to sign a release form in order to request medical record from previous Provider
All the appropriate tests, interviews and assessments were done prior to this patient being diagnosed with a bipolar 11 disorder-ruled out medical and drug causes of pt symptoms. (medically stable with normal lab TSH,CBC,A1C. Pt denied the use of any street drug)
Although there is no record here indicating family and friends were interviewed, I would assume they were, as it is important to seek input of patient behavior from other close sources to make a this diagnosis of Bipolar 11.
According to Wheeler, K. (2014), while medication is considered the first line of treatment is Bipolar disorder, multiple studies have shown with increasing evidence that the course of the disease can be further modified by interventions that target the three factors associated with relapse in BD; stressful life events, medication non-adherence and disruptions in social rhythms. I would therefore suggest that this patient should in addition to medication which she clearly sought in this case presentation, be encouraged to participate in interpersonal psychotherapy.
References
Jucevičiūtė, N., Žilaitienė, B., Aniulienė, R., & Vanagienė, V. (2019). The link between thyroid autoimmunity, depression and bipolar disorder. Open Medicine, 14(1), 52-58.
Kaplan, H. I., Sadock, B. J., Boland, R. J., Verduin, M. L., Sadock, V. A., & Ruiz, P. (2021). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. Wolters Kluwer.
Menezes, I. C., von Werne Baes, C., Lacchini, R., & Juruena, M. F. (2019). Genetic biomarkers for differential diagnosis of major depressive disorder and bipolar disorder: a systematic and critical review. Behavioural brain research, 357, 29-38.l
O’Donovan, C., & Alda, M. (2020). Depression preceding diagnosis of bipolar disorder. Frontiers in psychiatry, 11, 500.
Pinna, M., Visioli, C., Rago, C. M., Manchia, M., Tondo, L., & Baldessarini, R. J. (2019). Attention deficit-hyperactivity disorder in adult bipolar disorder patients. Journal of affective disorders, 243, 391-396.
Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse: a how-to guide for evidence-based practice.
American Psychiatric Association, & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA.