NRNP 6665 WEEK 4 Assessing, Diagnosing, and Treating Adults With Mood Disorders
Subjective:
CC (chief complaint): “I am here for a mental health assessment.”
HPI: P.P. is a 28-year-old female patient who came to the facility to seek a mental health assessment. She reports a history of stopping the use of her medications, indicating that they squash her creativity and personality. She indicates that she has been experiencing episodes of high energy, creativity, and reduced need for sleep, which has gone on for about a week, and durations of depression when she finds it difficult to get out of her bed. She also has a history of cases of hospitalizations, and she was recently hospitalized due to suicidal ideation and attempts. She also reports auditory hallucinations whenever she struggles to sleep. P.P. also reports negative side effects of medications such as Zoloft, which led to insomnia and made her feel high, while Seroquel led to weight gain.
Substance Current Use: She reports smoking a pack of cigarettes a day. She last drank alcohol at the age of 19. She denies the use of other drugs and substances such as cocaine or marijuana
Medical History:
- Current Medications: She is currently taking unnamed medications for hypothyroidism and birth control pills for polycystic ovaries
- Allergies: No known allergies reported
- Reproductive Hx: The patient has regular menstrual cycles, with the last one being experienced last month. No chance of pregnancy was reported. Reports engaging in frequent unsafe sexual activity with several partners.
ROS:
- GENERAL: Denies weight loss, fatigue, chills or fever. However, she reports variable energy levels associated with mood cycles
- HEENT: Denies head trauma, headaches, vision changes, hearing loss, or sore throat.
- SKIN: No skin itches, lesions, or rashes
- CARDIOVASCULAR: Denies chest pain, palpitations or edema
- RESPIRATORY: No wheezes, cough, or breath shortness.
- GASTROINTESTINAL: NO constipation, diarrhea, vomiting, or nausea. She reports appetite changes depending on her mood
- GENITOURINARY: No hematuria, dysuria, or changes in urinary frequency. Reports regular menstrual cycles
- NEUROLOGICAL: No seizures, dizziness, or headaches. She reports high energy and decreased need for sleep, which is followed by depressive episodes.
- MUSCULOSKELETAL: Denies joint or muscle stiffness, swelling, or pain
- HEMATOLOGIC: Denies bleeding or bruising
- LYMPHATICS: No swollen lymph nodes
- ENDOCRINOLOGIC: Reports a history of hypothyroidism. No polydipsia or polyuria. Reports no heat or cold intolerance and no sweating
Objective:
Vital signs: Temp 98.2 Pulse 90 Respiration 18 B/P 138/88
Diagnostic results: 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)
Assessment:
Mental Status Examination: The patient is a 25-year-old female patient who looks her age. She is decently dressed and well-groomed. She is alert and oriented. She shows a cooperative but guarded attitude. She exhibits a range of behaviors; she looks engaging and animated when talking about her creative projects but withdrawn when talking about her depressive episodes. Her memory is intact. She exhibits variable moods and a labile affect. She displays frustration and irritability when discussing family dynamics and medication history. She exhibits pressured and rapid speech. Her thought process is circumstantial and tangential. She denies current suicidal ideation or homicidal ideation but acknowledges a past suicide attempt.
Diagnostic Impression:
- Bipolar I disorder: This is a condition characterized by at least a manic episode, which may be followed or preceded by a major depressive or hypomanic episode (Carmassi et al.,2020). This patient reported manic symptoms. She reports engaging in harmful sexual activities and reports other symptoms such as racing thoughts, speaking a lot, sleep deprivation, inflated self-esteem, and extravagance. As such, based on the DSM-V criteria, the symptoms point to bipolar I disorder, making it the primary diagnosis.
- Borderline personality disorder: This patient displayed symptoms such as impulsivity and emotional instability, which are some of the symptoms experienced by patients with borderline personality disorder. However, she lacks chronic instability and identity disturbance, which are major symptoms of BPD (Fowler et al.,2021), making this condition less likely.
- Major depressive disorder: This is a condition with various symptoms, such as persistent feelings of sadness and hopelessness (Nussbaum, 2020). The patient reports low energy, excessive sleep, and feelings of worthlessness. However, the symptoms are not persistent, making this diagnosis less likely.
Reflections: I agree with the assessment since the patient presented with the symptoms, which mainly point to bipolar I disorder as the primary diagnosis. For example, the patient’s risky behavior, decreased need for sleep, and mood fluctuations all point to bipolar disorder (Tondo et al.,2022). One of the things learned from this case is the need for a thorough assessment in cases where a patient presents with symptoms that could indicate comorbidities (Rosenbaum et al.,2022). One of the things I would do differently is a further exploration of the patient’s non-adherence and why some medications negatively impact her creativity. It is vital to explore the ethical and legal considerations in such cases. For example, the patient has a history of non-adherence to medication regimen. Therefore, her autonomy should be considered when prescribing new medications and let her understand the benefits and potential side effects of the medication. The next is a duty to warn and protect. It is an ethical and legal obligation to protect this patient from potential harm since she has a history of suicidal thoughts and attempts (Hawton et al.,2022). Among the social determinants of health to consider is family support. The patient needs sufficient family support to help her manage the symptoms well and seek appropriate medical attention. As part of health promotion, the patient should be taught about stress prevention and management and why it is vital to engage in a healthy lifestyle with enough physical exercise, a balanced diet, and sufficient sleep.
Case Formulation and Treatment Plan: The patient doesn’t need any further laboratory tests at the moment. However, a referral to a psychiatrist can be indicated for ongoing disease management. In the case of bipolar I disorder, the patient should be started on lithium carbonate (300 mg), to be taken twice daily, integrated with weekly sessions of DBT to foster emotion regulation and coping skills development. The patient should be commenced on 10 mg of Lexapro once a day in the case of major depressive disorder, integrated with weekly sessions of CBT (Wang et al.,2021). A similar plan should be used in the case of BPD. While lithium may have side effects such as weight gain, nausea, and diarrhea, Lexapro can cause nausea, headache, insomnia, and dry mouth, among others. One of the major education points for this patient is to adhere to the medication regimen and plan. She should also report any adverse effects immediately they are experienced.
References
Carmassi, C., Bertelloni, C. A., Cordone, A., Cappelli, A., Massimetti, E., Dell’Oste, V., & Dell’Osso, L. (2020). Exploring mood symptoms overlap in PTSD diagnosis: ICD-11 and DSM-5 criteria compared in a sample of subjects with Bipolar Disorder. Journal of Affective Disorders, 276, 205-211. https://doi.org/10.1016/j.jad.2020.06.056
Fowler, J. C., Carlson, M., Orme, W. H., Allen, J. G., Oldham, J. M., Madan, A., & Frueh, B. C. (2021). Diagnostic accuracy of DSM-5 borderline personality disorder criteria: Toward an optimized criteria set. Journal of Affective Disorders, 279, 203-207. https://doi.org/10.1016/j.jad.2020.09.138
Hawton, K., Lascelles, K., Pitman, A., Gilbert, S., & Silverman, M. (2022). Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management. The Lancet Psychiatry, 9(11), 922-928. https://doi.org/10.1016/S2215-0366(22)00232-2
Nussbaum, A. M. (2020, December). Questionable agreement: The experience of depression and DSM-5 major depressive disorder criteria. In The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine (Vol. 45, No. 6, pp. 623-643). US: Oxford University Press. https://doi.org/10.1093/jmp/jhaa025
Rosenbaum, S., Morell, R., Abdel-Baki, A., Ahmadpanah, M., Anilkumar, T. V., Baie, L., … & Ward, P. B. (2020). Assessing physical activity in people with mental illness: 23-country reliability and validity of the simple physical activity questionnaire (SIMPAQ). BMC Psychiatry, 20, 1-12. 10.1186/s12888-020-2473-0
Tondo, L., Miola, A., Pinna, M., Contu, M., & Baldessarini, R. J. (2022). Differences between bipolar disorder types 1 and 2 support the DSM two-syndrome concept. International Journal of Bipolar Disorders, 10(1), 21. Doi: 10.1186/s40345-022-00268-2
Wang, X., Fan, Y., Li, G., & Li, H. (2021). The efficacy of escitalopram in major depressive disorder: a multicenter randomized, placebo-controlled double-blind study. International Clinical Psychopharmacology, 36(3), 133-139. Doi: 10.1097/YIC.0000000000000350
ORDER A PLAGIARISM-FREE PAPER HERE
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 risperidonevalproate (divalproex) ziprasidone |
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 | ||||||