CC (chief complaint): “I sometimes forget to take my medications”
HPI: A.T. is a 27-year-old female patient who came to the psychiatric clinic with a history of mood disorder. She reports that she has been missing her doses due to forgetfulness. She has a history of hypertension which she manages with Trandate 100mg twice daily. She denies previous suicidal gestures.
Past Psychiatric History:
- General Statement: The patient’s psychiatric history is unremarkable. She was diagnosed with bipolar disorder ever since she was a young girl.
- Caregivers (if applicable): The patient’s parents got divorced about 10 years ago, and she has been staying with her mother ever since. She recently got her first child about 2 months ago.
- Hospitalizations: No hospitalization history.
- Medication trials: The patient has been taking mood stabilizers, but she has not been compliant due to forgetfulness.
- Psychotherapy or Previous Psychiatric Diagnosis: Denies any history of psychotherapy for her current or past mental condition.
Substance Current Use and History: The patient claims to have never taken alcohol or smoked cigarettes. She also denies using any other illicit drug of abuse.
Family Psychiatric/Substance Use History: The patient reports that her brother committed suicide through GSW. She also reports that her brother was addicted to methamphetamine.
Psychosocial History: The patient recently got her fast child two months ago. She worked in the community library for 5 years, but currently lives with her mother. The patient’s parents got divorced about 10 years ago, and she has been staying with her mother ever since. She has two sisters who live in a different town. She is a bachelor’s degree graduate, majoring in Literature.
- Current Medications: Trandate 100mg PO twice daily for HTN
- Allergies: Denies food or environmental allergies.
- Reproductive Hx: Heterosexual with the first child 2 months old.
- GENERAL: The patient is healthy with no fever, headache, dizziness, urination issue, or chest pain.
- HEENT: Head: atraumatic. Eyes: No visual changes, blurred vision, use of corrective lenses, or red/itchy eyes. Nose: No congestion, irritations, inflammation, nose bleeding, or sinus problems. Throat & Mouth: No sore throat, bleeding gums, or swallowing difficulties.
- SKIN: Denies discoloration, hives, rashes, blisters, lumps, or ulcers.
- CARDIOVASCULAR: Denies chest pressure, pain, edema, or palpitations.
- RESPIRATORY: No wheezing, sneezing, dyspnea, coughing, or chest congestion.
- GASTROINTESTINAL: No abdominal pain, hernia, constipation, diarrhea, or changes in bowel movement.
- GENITOURINARY: No changes in urine frequency, urgency, or burning sensation when urination. Report normal vaginal discharge.
- NEUROLOGICAL: No headache, changes in vision, loss of consciousness, or dizziness.
- MUSCULOSKELETAL: exhibits full ranges of movement in both upper and lower extremities. No joint stiffness or pain.
- HEMATOLOGIC: No bleeding problems or prolonged healing of wounds.
- LYMPHATICS: No signs of enlarged lymph nodes.
- ENDOCRINOLOGIC: Denies polyuria, polyphagia, or polydipsia. No hypothyroidism.
Vital Signs: T- 98.9 P- 97 R 22 150/88 Ht 5’5 Wt. 135lbs
HEENT: Head is atraumatic and normocephalic. Pupils are equal in size, round, and equally reactive to light. No erythema or effusion on the tympanic membrane. No discharge or swelling was noted in the ear canals. The neck is supple with anterior cervical lymphadenopathy. The throat is clear with no swelling and exudates. Tonsils are not swollen.
Chest/lungs: Breathing sounds clear to auscultation
Heart: Regular heart rate, with S1 and S2 sounds. S3 absent. No gallop, rales or murmurs.
Abdomen: Non-distended and soft abdomen with no hernia. Normal sounds were noted in all four abdominal quadrants.
Diagnostic results: No tests ordered.
Mental Status Examination: The 27-year-old female patient walked in well-groomed in age-appropriate clothes. The patient maintains eye contact during the interview with appropriate facial expressions. Communicates in a clear language, in a normal tone, and rate of speaking. Her thought process is coherent and logical. She denies delusion, hallucinations, and suicidal ideation. She confirms being forgetful, but her long-term memory is intact. Her insight is absent. The patient displays limited ability to identify the consequences of her actions. Denies suicidal ideation, or a history of suicidal attempts.
- Bipolar Disorder: According to the DSM-V. bipolar disorder has been defined as a group of mental disorders characterized by extreme fluctuations in the patient’s mood, ability to function, and energy level. There are three main types, but the patient in the provided case study presented with signs of bipolar 1 disorder, which is characterized by manic-depressive episodes (Miskowiak et a., 2018). DSM-V requires the patient to display at least 3 of the following symptoms, racing thoughts, talkativeness, lack of sleep, inflated self-esteem, distracted easily, and psychomotor agitation among others.
- Schizophrenia: according to the DSM-V diagnostic criteria, schizophrenia disorder is diagnosed when the patient displays at least two of the following 5 symptoms, incoherent or disorganized speaking, hallucination, delusion, unusual or disorganized movement, and negative symptoms (Tulacı, 2018). The patient in the provided case study does not meet the diagnosis of this disorder.
- Major Depressive Disorder (MDD): For a patient to qualify for the diagnosis of MDD, the DSM-V require the presence of at least 5 of the following symptoms within the same two-week period, sleep disturbance, fatigue, worthlessness, weight changes, depressed mood, loss of pleasure and indecisiveness among others (Hasin et al., 2018). The patient in the provided case study presented with a depressed mood, but does not qualify for this diagnosis.
Reflections: The provided patient information is quite substantial to make a diagnosis of bipolar disorder. The clinician did an excellent job collecting information that provides a clear picture of the patient’s symptoms, such as manic and depressive episodes. However, additional information is still missing, to determine the severity of the condition (McIntyre & Calabrese, 2019). The PMHNP also needs to consider the use of screening tools such as mood disorder questionnaires to confirm the primary diagnosis and rule out the differentials (Andersson et al., 2019). Additionally, given that the patient’s condition might affect her life at home, it is necessary to inform the patient mother about her symptoms and how to manage her condition, with her consent. Her mother will help by reminding her to take her medication every time she forgets to promote a positive outcome.
Andersson, G., Carlbring, P., Titov, N., & Lindefors, N. (2019). Internet interventions for adults with anxiety and mood disorders: a narrative umbrella review of recent meta-analyses. The Canadian Journal of Psychiatry, 64(7), 465-470.
Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry, 75(4), 336-346. doi:10.1001/jamapsychiatry.2017.4602
McIntyre, R. S., & Calabrese, J. R. (2019). Bipolar depression: the clinical characteristics and unmet needs of a complex disorder. Current medical research and opinion, 35(11), 1993-2005. https://doi.org/10.1080/03007995.2019.1636017
Miskowiak, K. W., Burdick, K. E., Martinez‐Aran, A., Bonnin, C. M., Bowie, C. R., Carvalho, A. F., … & Vieta, E. (2018). Assessing and addressing cognitive impairment in bipolar disorder: the International Society for Bipolar Disorders Targeting Cognition Task Force recommendations for clinicians. Bipolar disorders, 20(3), 184-194.
Tulacı, Ö. D. (2018). Differences in psychopharmacology of pediatric schizophrenia and adult schizophrenia. Klinik Psikofarmakoloji Bulteni, 28, 338-339. https://www.proquest.com/openview/0d5cf61a680c733184a8abce17abb31b/1?pq-origsite=gscholar&cbl=28708