Assignment: Assessing, Diagnos
In this Assignment you will assess, diagnose, and devise a treatment plan for a patient in a case study who is presenting with a mood disorder.
- Review this week’s Learning Resources. Consider the insights they provide about assessing, diagnosing, and treating mood disorders.
- Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
- Review the video, Case Study:
Petunia Park. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
- Consider what history would be necessary to collect from this patient.
- Consider what interview questions you would need to ask this patient.
- Consider patient diagnostics missing from the video: Provider Review
outside of interview:Temp 98.2 Pulse 90 Respiration 18 B/P 138/88Laboratory Data Available: Urine drug and alcohol screen negative. CBC within normal ranges, CMP within normal ranges. Lipid panel within normal ranges. Prolactin Level 8; TSH 6.3 (H)
Develop a Focused SOAP Note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:
- Subjective: What details did the patient provide regarding their chief complaint and symptomatology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
- Objective: What observations did you make during the psychiatric assessment?
- Assessment: Discuss the patient’s mental status
examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
- Reflection notes: What would you do differently with this client if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention that takes into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Required Readings (click to expand/reduce)
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
- Chapter 8, “Mood Disorders”
Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.
- Chapter 11, “Mood Disorders”
Walden University. (2021). Case study: Petunia
Park. Walden University Blackboard. https://class. waldenu.edu
Expert Answer and Explanation
Bipolar II Disorder Evaluation
CC: ” I have a history of taking medications and then stopping
them. I don’t think I need them. I really feel like the medication squashes who I am.”
HPI: Patient PP is a 25-year-old female patient who has come for a mental health assessment. The patient reports having problems with medication adherence, indicating her lack of need for the medication, stating that it “squashes” who she is. The patient also reports having been hospitalized as a teenager for going four to five days without sleep and hearing things during the period. Since then, she has been hospitalized four times, with the current hospitalization being the past spring. She notes that she has previously been diagnosed with bipolar, anxiety, and depression. She also notes that she tried to use some medications like Zoloft, Seroquel, and another one which she only recalls the name to start with the letter “L”. The patient explains that her prescribed medications seem to present some side effects. The patient also notes that she has once had some suicidal tendencies before. She also reports engaging in sexual intercourse with multiple partners since it elevates her moods. She also reports missing work due to feeling too depressed.
Substance Current Use and History: The patient reports smoking at least a packet of cigarettes a day, which she doesn’t intend to stop. She also reports having stopped using alcohol at 19 years. The patient also reports having a bad history of marijuana use which made her stop. She denies using cocaine, stimulant, inhalants, hallucinogens, and sedative medications. She also denies using any pain pills or opiate medications.
Family Psychiatric/Substance Use History: The patient reports having a family background with psychiatric and substance use issues. She indicates that her mother was bipolar with suicidal tendencies. She reports that her father was imprisoned for 8 to 10 years due to drug-related problems, and she considers her brother to also have mental issues though not hospitalized.
Psychosocial History: The patient was raised by her mother and her older brother. She currently lives with her boyfriend and at times her mother who is infuriated by her sexual habits. Her father is imprisoned and has not heard from him for some time. She has never been married before or had any children. She is currently working in her aunt’s stores albeit irregularly due to her occasional depressed moods. She is currently studying cosmetology and loves to paint and write.
Medical History: The patient has Polycystic ovary syndrome (PCOS) and hypothyroidism.
- Current Medications: the patient is currently under birth control pills for PCOS and an unnamed medication for hypothyroidism. She is also currently using some medication for her mental illness which she only remembers the first letter being “L.” She notes to have previously used Zoloft and Seroquel.
- Allergies:No allergies reported by the patient
- Reproductive Hx:The patient reports having her regular menses once a month, with the last one being sometime last month. She is diagnosed and under medication for PCOS. She reports being sexually active and with multiple partners
- GENERAL: Varying levels of eating and sleeping depending on the mood.
- HEENT: negative for head traumas, hearing, sight, smell, neck, or throat problems.
- SKIN: Negative for dryness, itching, or rashes.
- CARDIOVASCULAR: Negative for CV issues.
- RESPIRATORY: Negative for respiratory symptoms.
- GASTROINTESTINAL: Negative for GI pain, diarrhea, nausea, or vomiting.
- GENITOURINARY: Reports negative for GU symptoms.
- NEUROLOGICAL: Reports negative for neurological issues.
- MUSCULOSKELETAL: denies having any MS problems.
- HEMATOLOGIC: denies having any abnormal bleeding or hematologic issues.
- LYMPHATICS: Denies lymphadenopathy.
- ENDOCRINOLOGIC: Reports having hypothyroidism
- Vital signs: RR: 18, PR: 90, T: 98.2, B/P: 138/88
- HEENT: Noncontributory
- Res: No wheezing or distress in breathing
- CV: Regular HR, BP, no murmurs or bruits
Laboratory Data Available: The available laboratory results indicate negative for Urine drug and alcohol screen. The CBC, CMP, and lipid panel are within the optimal range. TSH levels indicative of subclinical hypothyroidism.
Mental Status Examination:
The patient appears well dressed for the occasion. She is alert and well oriented to time, place, person, and occasion. She maintains eye contact throughout the session. She also appears to be hyper and chuckles throughout the interview. She answers the questions eloquently and has a good memory of several life events. but finds some questions about family and suicide irritating or personal. She denies having any delusions, nightmares, or paranoia. She confirms to have a history of suicidal ideation.
- Bipolar II Disorder DSM-5 296.89 (F31.81)- primary diagnosis
- Generalized Anxiety Disorder (GAD) DSM-5 300.02 (F41. 1)
- MDD, Severe recurrent unspecified DSM-5 296.23 (33.9)
From the presented information and assessment of the patient’s condition, the selected primary diagnosis is bipolar II disorder. Bipolar II disorder is a mood disorder characterized by hypomania and depression. The condition causes unusual mood changes, energy level, concentration, and ability to perform routine activities, which if left untreated can cause severe harm or even death to the patient or those around the patient among other serious consequences (CrashCourse. 2018). The selection of bipolar II disorder as the primary diagnosis was based on the DSM guidelines which indicate the presence of at least five symptoms. From the information obtained, the symptoms that seem to align with the primary diagnosis include having depression and hypomanic episodes, significant changes in eating and sleeping patterns as a result of mood changes, occasional loss of interest in daily activities, including those that are considered fun to do, and compulsive behavior.
The presented case provides insight into a patient with possible bipolar disorder. The patient presents various aspects that put her at risk of getting a mood disorder. Some of these risk factors include a family history of mental illness, and a diagnosis of PCOS, whereby, evidence shows that patients with PCOS have an increased likelihood of getting the condition (Qadri et al., 2018). One of the aspects that should be considered when creating a suitable treatment plan is the fact that the patient has hypothyroidism. According to a study by Li et al. (2019), hypothyroidism was noted to be the commonest abnormality among patients with bipolar disorder. Some of the treatment options for hypothyroidism like lithium could have some reactions when dealing with patients with bipolar disorder and should therefore be considered when implementing the treatment plan. One of the ethical considerations for this case is beneficence and non-maleficence, whereby, the patient’s wellbeing will be given priority when selecting the most appropriate treatment plan. This includes selecting medication in consideration of the potential interactions and adverse effects that could affect the patient and her history of nonadherence.
Since the patient is using lithium for hypothyroidism, she could also use the same for bipolar but with dosage adjustments to prevent adverse reactions reported earlier. This selection is based on the study by Volkmann et al. (2020), which supports the medication as a first-line treatment option for bipolar disorder. Follow-up should be done after a month to confirm the patient’s adherence to the treatment therapy and tolerability of the drug. Patient education on responsible and safe sexual behavior is important to reduce the risk of getting sexually transmitted infections or unwanted pregnancy, among other issues.
CrashCourse. (2014, September 8). Depressive and bipolar disorders: Crash course psychology #30 [Video]. YouTube. https://www.youtube.com/watch?v=ZwMlHkWKDwM&t=1s
Li, C., Lai, J., Huang, T., Han, Y., Du, Y., Xu, Y., & Hu, S. (2019). Thyroid functions in patients with bipolar disorder and the impact of quetiapine monotherapy: a retrospective, naturalistic study. Neuropsychiatric Disease and Treatment, 15, 2285. https://doi.org/10.2147/NDT.S196661
Qadri, S., Hussain, A., Bhat, M. H., & Baba, A. A. (2018). Polycystic Ovary Syndrome in Bipolar Affective Disorder: A Hospital-based Study. Indian journal of psychological medicine, 40(2), 121–128. https://doi.org/10.4103/IJPSYM.IJPSYM_284_17
Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium treatment over the lifespan in bipolar disorders. Frontiers in Psychiatry, 11, 377. https://doi.org/10.3389/fpsyt.2020.00377
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