NRNP 6665 Assessing, Diagnosing, and Treating Adults With Mood Disorders
Subjective:
CC (chief complaint): Miss Petunia Park visits the clinic for a mental health assessment as she has been having some depressive symptoms.
HPI:
Miss Park reports she has been experiencing some depressive episodes around four to five times per year. During this period, she usually does not want to get out of bed as she has no energy or motivation to do anything. In addition, she experiences anhedonia, hypersomnia, increased appetite, and feels worthless. The symptoms occur after she has been awake for up to five days working on writing, painting, and music, where she feels she has a lot of energy for a week. She also reports that during this period, her friends tell her she talks too much and appears scattered. During an episode, she says there are voices telling her how great she is, does not eat a lot, and experiences insomnia. She also engages in a lot of sex, as she feels excited and thrilled to find new people to explore sex.
Miss Park was first diagnosed with a mental health illness during her teen years when she did not sleep for four to five days and was having some hallucinations. She reports she has had four previous hospital admissions, with the last being in spring, and none was for detox. She also reports that one of her admissions in 2017 was after she overdosed on Benadryl following suicidal ideations but denies having any of them since then. She has been previously diagnosed with depression and anxiety disorders and prescribed Zoloft, Risperidone, Seroquel, and Klonopin. However, she reports not using them as Zoloft made her feel high, risperidone and Seroquel were associated with weight gain, and Klopin made her slow, and only one drug she cannot recall the name seemed to work, but it interrupted her creativity.
Substance Current Use: The patient reports that she only smokes tobacco and denies using any other substance.
Medical History:
- Current Medications: Miss Park reports she is on birth control and some medications for her hypothyroidism.
- Allergies: She denies any allergies.
- Reproductive Hx: The patient is sexually active, has multiple sexual partners, and lives with the boyfriend but denies being pregnant or having any children.
ROS:
- GENERAL: The patient denies being in any discomfort or body weakness.
- HEENT: The patient denies nasal or ear discharge and eye swelling or pain.
- SKIN: The patient reports having pimples on her face and hair distribution on her body but denies erythema and hyperpigmentation.
- CARDIOVASCULAR: The patient denies any orthopnea, paroxysmal nocturnal dyspnea, and palpitations.
- RESPIRATORY: The patient denies any chest pain, cough, and dyspnea.
- GASTROINTESTINAL: The patient reports experiencing increased or decreased appetite but denies any abdominal pain and bowel changes.
- GENITOURINARY: The patient denies dysuria, hematuria, and abnormalities in vaginal discharge and menstrual blood.
- NEUROLOGICAL: The patient denies headaches, loss of consciousness, or memory loss.
- MUSCULOSKELETAL: She denies joint pain and stiffness or muscle pain.
- HEMATOLOGIC: She denies experiencing increased fatigue, abnormal bruising, and high fevers.
- LYMPHATICS: She denies noticing any swollen lymph nodes.
- ENDOCRINOLOGIC: Miss Park reports she occasionally has hirsutism, increased thirst, and cold intolerance.
Objective:
Diagnostic results: No diagnostic tests were ordered.
Assessment:
Mental Status Examination:
Miss Park is well-groomed and oriented in time, place, and person. She appears agitated, speaks in a normal tone and rhythm, and has a depressed mood, grandiose delusions, and auditory hallucinations. She also has a normal attention and concentration span, intact memory, abstract thought, good judgment, and partial insight.
Diagnostic Impression:
Bipolar I Mood Disorder (BMD): BMD is an example of DSM-V mood disorder characterized by a manic episode followed by a major depressive episode. Manic symptoms seen in Miss Parker include a five-day history of elevated mood and increased energy accompanied by increased self-esteem, talking, decreased need to sleep, grandiosity, and goal-directed activity like painting (Brieler et al., 2021). She has also been engaging in high-risk sexual behavior during this period. The symptoms have also resulted in hospitalization, and they affect her social life and occupation status.
Major Depression Disorder (MDD): MDD is also an example of a mood disorder characterized by a depressed mood and loss of interest that have lasted for a long duration of time, as seen in Miss. Parker (Christensen et al., 2020). In addition, Miss Parker has experienced other depression symptoms, such as hypersomnia, psychomotor retardation, and decreased energy levels. She has also felt worthless and had suicidal thoughts during this period.
Schizophrenia: Schizophrenia is an example of a DSM-V psychotic disorder characterized by hallucinations, delusions, abnormal speech and behavior, and catatonia (Ravichandran et al., 2020). In this case, Miss Parker has some of the symptoms, including bizarre behavior, grandiose delusions, and auditory hallucinations.
Case Formulation and Treatment Plan:
Psychotherapy: I would recommend cognitive-behavioral therapy (CBT). CBT is the preferred form of psychotherapy used in bipolar patients as it helps manage manic and depressive episodes by helping the patient identify the cause of the mood episodes, develop coping strategies to ease the symptoms, and enhance treatment adherence to drug treatment (Özdel et al., 2021).
Pharmacotherapy: I would prescribe fluoxetine 25 mg and olanzapine 10 mg PO OD (Yalin et al., 2020).
Alternative therapy: I would recommend psychoeducation, a psychotherapy method associated with a reduction in the frequency of new mood episodes, number of hospital admissions, and length of stay (Rabello et al., 2021). It also improves pharmacological treatment adherence when used in patients.
Health Promotion and Patient Education: I would educate Miss Parker about her symptoms and encourage her to adhere to her medications and psychotherapy sessions. I would also inform her of the expected side effects and report if they are severe for medication reevaluation (Bhattad et al., 2022). I would also advise her on healthy sexual practices to avoid the risk of unwanted pregnancies and sexually transmitted infections.
Reflections: If I were to conduct another session, I would ask Miss Parker about her creative work, which includes writing, painting, and music, and whether it is a passion she would wish to pursue as a career (Ee et al., 2020). I would also like to inquire about her relationship with her mother, aunt, and boyfriend and understand how each of them supports her when she experiences manic and depressive episodes.
References
Bhattad, P. B., & Pacifico, L. (2022). Empowering Patients: Promoting Patient Education and Health Literacy. Cureus, 14(7). https://doi.org/10.7759/cureus.27336
Brieler, J. A., & Keegan-Garrett, E. (2022). Diagnosis and Treatment of Bipolar Illness in the Primary Care Office. Missouri Medicine, 119(3), 213-218. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9324725/
Christensen, M. C., Johnny Wong, C. M., & Baune, B. T. (2020). Symptoms of Major Depressive Disorder and Their Impact on Psychosocial Functioning in the Different Phases of the Disease: Do the Perspectives of Patients and Healthcare Providers Differ? Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00280
Ee, C., Lake, J., Firth, J., Hargraves, F., De Manincor, M., Meade, T., … & Sarris, J. (2020). An integrative collaborative care model for people with mental illness and physical comorbidities. International Journal of Mental Health Systems, 14, 1-16. https://ijmhs.biomedcentral.com/articles/10.1186/s13033-020-00410-6
Özdel, K., Kart, A., & Türkçapar, M. H. (2021). Cognitive Behavioral Therapy in Treatment of Bipolar Disorder. Noro Psikiyatri Arsivi, 58(Suppl 1), S66–S76. https://doi.org/10.29399/npa.27419
Rabelo, J. L., Cruz, B. F., Rodrigues Ferreira, J. D., Viana, M., & Barbosa, I. G. (2021). Psychoeducation in bipolar disorder: A systematic review. World Journal of Psychiatry, 11(12), 1407-1424. https://doi.org/10.5498/wjp.v11.i12.1407
Ravichandran, C., Ongur, D., & Cohen, B. M. (2020). Clinical Features of Psychotic Disorders: Comparing Categorical and Dimensional Models. Psychiatric Research and Clinical Practice, 3(1), 29-37. https://doi.org/10.1176/appi.prcp.20190053
Yalin, N., & Young, A. H. (2020). Pharmacological Treatment of Bipolar Depression: What are the Current and Emerging Options? Neuropsychiatric Disease and Treatment, 16, 1459-1472. https://doi.org/10.2147/NDT.S245166
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Assessing, Diagnosing, and Treating Adults With Mood Disorders
It is important for the PMHNP to have a comprehensive understanding of mood disorders in order to assess and accurately formulate a diagnosis and treatment plan for patients presenting with these disorders. Mood disorders may be diagnosed when a patient’s emotional state meets the diagnostic criteria for severity, functional impact, and length of time. Those with a mood disorder may find that their emotions interfere with work, relationships, or other parts of their lives that impact daily functioning. Mood disorders may also lead to substance abuse or suicidal thoughts or behaviors, and although they are not likely to go away on their own, they can be managed with an effective treatment plan and understanding of how to manage symptoms.
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.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
Learning Resources
Required Readings
- Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
- Chapter 6, “Bipolar Disorders”
- Chapter 2, “Neurodevelopmental Disorders and Other Childhood Disorders”
- Section 2.9, “Depressive Disorders and Suicide in Children and Adolescents” (pp. 174-180)
- Section 2.10, “Early-Onset Bipolar Disorder” (pp. 181-184)
- Chapter 7, “Depressive Disorders”
- Chapter 21, “Psychopharmacology”
- Chapter 22, “Other Somatic Therapies”
- Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.
- Chapter 11, “Mood Disorders”
- Document: Focused SOAP Note Template
Required Media
- CrashCourse. (2014, September 8). Depressive and bipolar disorders: Crash course psychology #30
- Links to an external site. [Video]. YouTube. https://youtu.be/ZwMlHkWKDwM https://www.youtube.com/watch?v=ZwMlHkWKDwM&t=1sLinks to an external site.
- Walden University. (2021). Case study: Petunia Park. Walden University Blackboard. https://waldenu.instructure.com
Medication Review
| Depression | Premenstrual dysphoric disorder | Seasonal affective disorder (MDD with Seasonal Variation) | |
|---|---|---|---|
| agomelatine amitriptyline amoxapine aripiprazole (adjunct) brexpiprazole (adjunct)bupropion citalopram clomipramine cyamemazine desipramine desvenlafaxine dothiepindoxepin duloxetine escitalopram fluoxetine fluvoxamine iloperidone imipramine isocarboxazid ketamine lithium (adjunct) l-methylfolate (adjunct)
|
lofepramine maprotiline mianserin milnacipran mirtazapine moclobemide nefazodone nortriptyline paroxetine phenelzine protriptyline quetiapine (adjunct) reboxetine selegiline sertindole sertraline sulpiride tianeptine tranylcypromine trazodone trimipramine venlafaxine vilazodone vortioxetine
|
citalopram desvenlafaxine duloxetin eescitalopram fluoxetin eparoxetine pepexev sarafe, sertraline venlafaxine |
Bupropion HCL extended-release |
| Bipolar depression | Bipolar disorder (mixed Mania/Depression | Bipolar maintenance | Mania | |
|---|---|---|---|---|
| lithium (used with lurasidone) lurasidone olanzapine-fluoxetine combination (symbyax) quetiapine valproate (divalproex) (used with lurasidone) |
aripiprazole asenapine carbamazepine |
olanzapine ziprasidone |
aripiprazole
lamotrigine |
aripiprazole asenapine carbamazepine lithium olanzapine quetiapine risperidone valproate (divalproex) |
To Prepare
- 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 138/88
Laboratory 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)
The Assignment
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-TR 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: Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.).
By Day 7 of Week 4
Submit your Focused SOAP Note.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK1Assgn+last name+first initial.
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Rubric
NRNP_6665_Week4_Assignment_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning Outcome Create documentation in the Focused SOAP Note Template about the patient in the case study. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS |
|
15 pts | ||||
| This criterion is linked to a Learning Outcome In the Objective section, provide:• Review of Systems (ROS) documentation and relate if pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses |
|
15 pts | ||||
| This criterion is linked to a Learning Outcome In the Assessment section, provide:• Results of the mental status examination, presented in paragraph form• At least three differentials with supporting evidence. List them from top priority to least 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. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome In the Plan section, provide:• Your plan for psychotherapy• 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. • Incorporate one health promotion activity and one patient education strategy. |
|
25 pts | ||||
| This criterion is linked to a Learning Outcome • Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.). |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). |
|
10 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for parenthetical/in-text citations and reference list. |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and punctuation |
|
5 pts | ||||
| Total Points: 100 | ||||||