NRNP 6675 WEEK 9 Response NO 1 to my colleague DEBORAH, M Grand Discussion post no 1

******PLEASE ANSWER TO MY COLLEAGUE DEBORAH M, DISCUSSION POST BELOW BY ANSWERING THIS QUESTION NO 1*****
What Are the differences between Bipolar I and Bipolar II Disorder?

 

Week 9: Case Study

College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
April 28, 2022

 

NRNP 6675 Case Study
This presentation involves a 43-year-old Caucasian female who self-presents for an initial psychiatric evaluation using an evidence-based and DSM-V as a guideline. This case study aims to provide an overview of symptom management.

NRNP 6675 Learning Objectives:
By the conclusion of this presentation, you should be able to effectively:
• Recognize the signs and symptoms of Bipolar I in a patient in alignment with the DSM-V.
• Discuss the differential diagnosis for Bipolar I.
• Use evidence-based care approaches in decision-making in formulating a treatment plan.

Subjective:
CC: “I’m tired of my mood fluctuations; I just want to have a less stressful lifestyle.”

HPI: K.B. is a 43-year-old Caucasian female. She presents to the clinic as a first-time patient for an initial psychiatric evaluation. She states that the reason for her visit is that “I’m tired of my mood fluctuations; I just want to have a less stressful lifestyle.” She has a history of ADD, Anxiety, and Bipolar I. She reports that her mood for the past two to four weeks fluctuates a lot and that she “wasn’t in good spirits” related to a “toxic environment at work and stress at home.”

She states that she is unable to focus at work on some days. She initially took a leave of absence at work after she had an “episode” with one of her colleagues, causing her to cause a disruption in work in which they were unable to calm her down. Following the episode, a few weeks later, she decided to quit her job of five years.

She reports wanting to take some time off, but she sometimes reports not having enough energy to search for a job physically. However, she feels that she should continue searching for a job so that she doesn’t have to be at home with her husband on the days that he does come home early from work, making matters worse because she says sometimes, she has the time to match his energy causing her to go on uncontrollable tangents making it hard to calm down.

She reports that her stress and irritability have increased at home because her husband of twenty years no longer wants to be married. She reports that his patterns have changed; he is staying a lot later on weekdays at work, stating that he is working later hours which she does not believe is the case. When this does happen, she states that he comes home finding something to start an argument with her about.

She reports that he is overly protective of his cell phone and “all of a sudden needs so much privacy when taking calls now.” She suspects infidelity and states that he hasn’t behaved in a manner before during their marriage. She reported wanting to start therapy with him, and he doesn’t believe that their marriage is salvageable.

K.B says that between the toxic environment at work and home, she doesn’t know what to do, and the only time that she is happy and less stressed out is when her children come home to visit three to four times a month. She reported that recently she had suicidal ideations without a plan due to lying in bed for days because she didn’t feel like doing anything.

She frequently has decreased energy, which she states fluctuates. She started changing her mind about “no longer wanting to be here” because she wanted to see her children become married and have kids of their own one day. She reported not getting a lot of sleep on most nights and experiencing nightmares once and a while about when she was molested, but she forces herself to stay awake because she doesn’t feel like she needs sleep on some days.

She stated that her personal life and her stress at work have caused her to lose her appetite on most days and that she has lost a lot of weight.
She has a history of being molested from the age of 12 -to 14 years old; in which she stated that she saw a therapist during that time frame and has not seen one since then.

She remembered being on medication before for it but cannot recall the names of the medication. She states that she is working on better terms with her parents and that their relationship is “complicated,” She chose not to elaborate on it further. She has a brother in which she states she communicates with him regularly but sees him when she can.

She reports being hospitalized for ten days in a behavioral health unit and stated that she was given Seroquel during her admission. She does not take anymore due to her not liking to take medication but understands she needs to “get better.”
She was intermittently teary-eyed during the session, in which she was encouraged that she did not have to apologize for crying.

At times she would try to make light of her situation by making comments about her husband, saying,” I know this isn’t funny,” but continued to laugh, and some of the comments were not congruent with the subject matter. She stated a few times that everything was a lot and that she was ready to participate in her care, taking as little medication as she could, which she and the provider both agreed to until further notice.

Medical History: Stage One CKD, Colon Polyps, Benign Stomach Tumor, and Asthma.
Surgical History: Appendectomy, Abdominoplasty, and a Splenectomy.
Substance Current Use: K.B. denies engaging in illicit drugs and smoking cigarettes. She reports drinking one to two glasses of wine socially once per month. She states that her parents used to drink alcohol in the past. She denies anyone in the family having any drug or alcohol-related issues.

Family Psychiatric History: K.B reports that her maternal mother had anxiety and a suicide attempt when she was younger. She stated that she believes that her father has “undiagnosed Bipolar.” It is unsure if any other of her family members had any psychiatric illnesses. She denies her family members having suicidal ideations or committing suicide.

She reports that she was diagnosed with ADD at 12 and anxiety and Bipolar I Disorder with manic depression in her adulthood. She reports seeing a therapist for two years, but she stopped seeing her at 14. She does not currently see a therapist.
She stated that she was hospitalized for ten days last year due to stress at home and work.

She reports that she was prescribed psych meds when she was younger. However, she cannot recall what she was taking and states she prefers not to take medication. She states that when she was in the hospital, she was given Seroquel, but she was not med compliant. She denies having a history of suicidal ideations. She denies current suicidal ideations or self-harm. She denies audio and visual hallucinations.

She reports anxiety 5/10 depending on the day.
Developmental Milestones: The client met all developmental milestones at the appropriate age.

Psychosocial History: K.B is a 43- year-old Caucasian female. She is married and has two daughters, 18 and 19. She has an older brother in which they both were raised by her parents and spent every summer with her grandparents growing up as a child. She currently lives in San Antonio, Texas, with her husband. Her kids are both away in college.

K.B attended school her entire life in many areas of Texas, and she also graduated from college with a master’s degree in business. She recently took a leave of absence at work and eventually quit her job as a project manager related to a “toxic work environment.”

K.B has a history of physical, emotional, and mental abuse. She reports that a family friend her parents used to bowl with molested her at 11. She also stated that “the toxic environment at work sometimes restarts the trauma. She denies having been arrested, convicted, or having a legal history.
Medical History:

Current Medications: Melatonin 3 mg H.S. (OTC, as needed).
Allergies: Denies any medication, environmental, or food allergies.
Reproductive Hx: Heavy menstrual cycle.
ROS: T 97.2 R 18 H.R. 84 Ht 5’2 B.P. 126/78 Wt 100 BMI 18.3

GENERAL: The patient presents as a 43-year-old Caucasian female. She is a&o x4. Her speech is of normal rate and normal volume. She has good eye contact. She appears to have good hygiene and is appropriately dressed. She is cooperative and pleasant during the interview. Her affect is congruent with her mood. She endorsed having suicidal ideations with no plan in the past; however, she denies homicidal ideations and audio and visual hallucinations.

She reports depression and anxiety 5/10 depending on the day. She denies having a fever, fatigue, or chills.

HEENT: No head traumas or injuries. No blurry vision or eye pain was noted. Denies hospitalizations, surgeries, floaters, cataracts, or glaucoma. No ear drainage, ear pain, hearing aids, tinnitus, or ear infections. No hearing loss in bilateral ears. No epistaxis sinusitis or recent changes in smell, obstruction, polyps, or rhinorrhea. No sneezing, runny nose, or congestion. No sores were noted in the mouth. No bleeding gums, gingivitis, or dentures. No sore throat.

SKIN: Warm and dry to touch, no cyanosis or skin tenting. No tattoos, moles, scarring, acne, or abrasions were noted. Black hair was noted on the body, full in texture. The scalp is free from abrasions. No rash or itching. No unusual bleeding or bruising was noted. Nails are free from clubbing.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort, No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough, and congestion. Denies hemoptysis.
GASTROINTESTINAL: Symmetrical, round abdomen, and non-tender. Normoactive bowel sounds were noted in all four quadrants. No friction rub was noted to the liver and spleen on auscultation. No tenderness was noted on all four quadrants. No masses or hernias were noted.
GENITOURINARY: No burning on urination, no urgency, hesitancy, odor, or color. Normal sphincter, no hemorrhoids, masses palpable.
NEUROLOGICAL: A&0x2-3, normal affect, and speech. Denies seizures, numbness, and tingling. C.N. 2-12 normal. DTRs normal in all extremities. Gait is steady and balanced.
MUSCULOSKELETAL: No muscle pain, joint pain, or stiffness noted.
HEMATOLOGIC: No anemia, bruising, or bleeding noted.
LYMPHATICS: No enlarged nodes or history of splenectomy noted.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance noted.

NRNP 6675 Objective:
Diagnosis: Bipolar 1, Attention Deficit Disorder, and Anxiety.
Differential Diagnosis: Major Depressive Disorder, Post Traumatic Stress Disorder, and Borderline Personality Disorder.
Bipolar Disorder is a mental illness that causes dramatic shifts in a person’s mood, energy, and ability to think clearly. People with bipolar experience high and low moods, known as mania and depression, which differ from the typical ups-and-downs most people experience (Bipolar Disorder | NAMI: National Alliance on Mental Illness, 2017, para. 1).

Bipolar Disorder is the primary diagnosis for this patient. According to (Bipolar Disorder | NAMI: National Alliance on Mental Illness, 2017), K.B. presents with many symptoms such as having a decreased need for sleep, pressure to keep talking at work, arguing with her colleagues, and at times in her home environment when she is having a dispute with her husband.

She has also endorsed fluctuating mood swings, which have led to her being manic at work and, at times, feeling depressed, insomnia, suicidal ideations, feelings of worthlessness, and a loss of energy.
Major Depressive Disorder (MDD), or clinical depression, affects how you feel, think and behave and can lead to a variety of emotional and physical problems and is a mood disorder that causes a persistent feeling of sadness and loss of interest (Depression (Major Depressive Disorder) – Symptoms and Causes – Mayo Clinic, 2021, para. 1).

According to the (Association 2013), five symptoms must be present in two weeks: difficulty making decisions, feelings of worthlessness, suicide attempts, insomnia, and a loss of interest in once enjoyed activities.

K.B has a history of nightmares from the trauma of the molestation, causing her to have insomnia; she has faced challenges at work, causing her to act on bad decisions that led to her having a manic episode as well as suicidal ideations without a plan which caused her to feel worthlessness. As a result of her past experiences, this makes this a diagnosis for her.

Post-Traumatic Stress Disorder (PTSD) is a mental health condition where you struggle to recover long after you experience or witness a deeply terrifying event relating to such events as a natural disaster, accident, combat, or sexual violence (Krouse, 2021, What Is Post-Traumatic Stress Disorder (PTSD)? section).

According to the (Desk Reference to the Diagnostic Criteria from Dsm-5, 2013), people who experience PTSD have been exposed to threatened death, serious injury, or sexual violence, including witnessing and experiencing the event directly and learning that such events may have occurred to a close friend or family member.
K.B. reported being molested by a friend of the family they used to go bowling with.

As a result, she experiences trauma triggered by a toxic work environment, irritability, and sleep disturbance. For this reason, I am diagnosing K.B. with this possible differential diagnosis.
Borderline Personality Disorder is a mental health disorder that impacts how a person thinks and feels about themselves and others, causing problems functioning in everyday life that including self-image issues, difficulty managing emotions and behavior, a pattern of unstable relationships, inappropriate anger, impulsiveness, and frequent mood swings (Borderline Personality Disorder – Symptoms and Causes – Mayo Clinic, 2021, Overview section).

Individuals with this disorder will exhibit a pattern of unstable and intense interpersonal relationships, a disturbance in their identities, such as having a persistently unstable sense of self, and episodic dysphoria (Association, 2013).
K.B has displayed trying to maintain her marriage to her husband, although he does not want to continue to be married. She has also exhibited inappropriate anger both at work and at home.

She endorsed suicidal ideations in which she did not have a plan and presented as being in an unhealthy unstable relationship. For these reasons, this is a possible differential diagnosis for her.

Assessment:
Mental Status Examination: The patient is a 43-year-old Caucasian female who looks her stated age. She is a&ox4. Her speech is of normal rate and normal volume. She has good eye contact. She appears to have good hygiene and is appropriately dressed. She endorsed having suicidal ideations with no plan in the past; however, she denies having homicidal ideations and audio and visual hallucinations.

She reports anxiety and depression 5/10 depending on the day. Her memory is intact. Psychomotor activity WNL. Her insight and judgment are fair. She is pleasant and cooperative during the interviewing process.

Reflections: I agree as I reflect on how my preceptor chooses to take special consideration about how effective medicating patients, especially those who are non-compliant with medication and have reservations about taking them in the first place. As providers, it is our responsibility to formulate a treatment plan that is specifically client-centered when incorporating a combination of pharmacological, nonpharmacological interventions, and psychotherapy.

It is essential to follow our scope of practice specific to our states as ethical and legal considerations may need addressing, such as incorporating prescribing independently formulating or collaborating with another provider when it is evidence-based medicine guidelines for preventive strategies in clinical practice (Lawrie et al., 2019).

The overall goal of treating patients in this environment is to develop and return meaningful results to individuals (Lawrie et al., 2019).
Case Formulation: K.B is a 43-year-old Caucasian female who self-presents to the clinic for an initial psychiatric evaluation with wanting to control her mood fluctuations and her stressful lifestyle.

Her strengths include willingness and agreeance to become more proactive and medication compliant with her treatment. Although she and her husband are not on the best of terms, she has the support of her brother. She is limited in her skills to cope with stress caused by a toxic environment at her place of employment, her marriage, and her history of molestation.

The client has presented with a history of mood fluctuations, increased stress, insomnia, nightmares, trauma, suicidal ideation, molestation, and unstable work and personal relationships. She meets the criteria for the DSM-5 for diagnosis of Bipolar One, which will be the primary focus of this visit due to the nature of the client’s noncompliance with medication.

We will focus on her ADD and anxiety diagnosis during her follow-up appointment.
Discussed the frequent client assessment using the Beck Anxiety Inventory Self-Assessment questionnaire, Adult ADHD Self-Assessment questionnaire, referral for therapy/PCP/PMHNP, labs, and health maintenance.

Expanded on the need to get her mood managed with medication first because of a lack of concentration related to anxiety and depression. The client will start Seroquel XL 50 mg P.O. H.S. to help regulate mood fluctuations, insomnia, and anxiousness. The client is in agreeance with adhering to the treatment plan as tolerated.

Her follow-up visit’s goal is to verbalize having an improved ability to manage her mood, stress, and behaviors and manage her thoughts in both her work (upon returning) and personal life. The client will return in two weeks.

Treatment Plan:
1. Referral to see a psychiatrist for outpatient therapy.
2. Follow up for two weeks with the PMHNP for medication management.
3. Health promotions include stress management, diet, coping skills, and adequate rest.
4. Follow up with the PCP for medical history, medication management, and labs.
5. Beck Anxiety Inventory / Adult ADHD Self-Assessment Questionnaire.
6. Encouraged and information provided for a support group.
7. Medication education, including side effects and compliance.
8. Return to clinic in two weeks; sooner if condition worsens.

Safety Plan: K.B. did not pose a threat to herself or others and was educated on the need to call emergency services if she experiences suicidal ideations.
The prognosis is reasonable, given the evidence for the efficacy of interventions discussed and medication compliance.

Conclusion: When formulating a treatment plan for this population, it is essential to keep in mind that the management success of this disorder includes a combination of living a healthy lifestyle, medication compliance, psychotherapy, and coping interventions.

NRNP 6675 Questions to consider for this case study:
1. What Are the differences between Bipolar I and Bipolar II Disorder?

 

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