NRNP6665 Week 4 Assessing, Diagnosing, and Treating Adults With Mood Disorders
Week (#4): (Petunia Park)
Walden NRNP6665: PMHNP Across the Lifespan 1
Petunia Park
Subjective:
Chief Complaint: Mental Health Assessment
History of Present Illness (HPI.): Ms. P.P. is a 19-year-old Mexican woman who is there for a mental health evaluation. According to Ms. Park, she was born on July 1st, 1995. She is not currently taking any medicine. She has a history of using drugs before quitting. She said, “I don’t think I need them,” Ms. Park.
I feel like my identity has been squashed by my medicine. Due to hearing voices and being hospitalized, the patient is still experiencing anxiety, despair, and manic episodes, as well as suspected OCD and schizophrenia. P.P. occasionally works at Aunt Bookstore. The patient said that she is a cosmetology student in vocational school. “I plan to apply makeup to Hollywood stars.”.
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General Statement: I will get enough information to come up with a treatment plan and maybe find some medications that will make you feel better without you feeling so squashed and having negative side- effects, but help you able to function through the day.
Caregiver: Ms. P is her caretaker but lives with her boyfriend; but sometimes stays with mom and brother when he gets mad for becoming and being promiscuous.
Hospitalization: Ms. Park stated: “When I was a teenager, my mother put me in the hospital after I went four or five days without sleeping. I think I may have been hearing things at that time”. [Chuckles]. Ms. Park stated she had been confined to hospitalization about four times. The last time was this past spring. No detox or residual rehab, though. One was in 2017. I overdosed on Benadryl, but I have not had those thoughts. Police picked her up and took her to the hospital once.
Medication trials: Ms. Park has taken Zoloft, which made her feel high and could not sleep, Risperidone, which made were mind race and gained a bunch of weight, Seroquel has increased importance as well, and Klonopin, which seemed to slow her down. I really cannot remember the others. “I think the one I just stopped helping.” It started with an “L,” I think. I do not reflect the name, but it squashed me in creativity.
Psychotherapy or Previous Psychiatric Diagnosis: Ms. Park stated depression, anxiety, and some bipolar and denies OCD. Not hearing or seeing thing right now (schizophrenia). Sometimes when I am not sleeping well, I listen to the voices telling me how great and wonderfully talented I am. It has been a couple of months since that happen.
Substance Current Use and History: Smokes about a pack a day, not going to quit for you either. Ms. P. drank alcohol at age 19, but it did not work well with me. Ms. Park denies using marijuana, cocaine, stimulants or methamphetamines, or any huffing or inhalant. Dismiss any sedative mediations such as Klonopin or Xanax, hallucinogenics like LSD, PCP, or mushrooms. Ms. P. does not use pain pills, or opiate medications, or anything prescribed or from the streets. Dismiss any synthetic like spice, ecstasy, Bath Salts, Mollies. Ms. Park denies any seizures or blackouts from drugs or alcohol use.
Family Psychiatric/Substance Use History: The mother perceives to be crazy. I think she had bipolar or something? My father went to prison for drugs, and I have not heard or seen from him since in eight or ten years. My brother, I think, is a little “schizo,” but he has never seen a doctor. My mother attempted to commit suicide. Ms. Park tried to cut herself and kill herself. There was abuse by their father, and him being hard on her, yelling a lot. Ms Park denied any sexual abuse or physical abuse.
There was emotional and possible mental abuse in the yelling and her behavior.
Medical History: Ms. Park states she has thyroid issues and polycystic ovaries, loves sex, and loves to explore sex with different men.
Current Medications: None. Ms. P had tried several medications; her recent history of taking and then stopping them is a reliving problem. Ms. P. is on birth control pills for polycystic ovaries. Her medications were Zoloft, which made her feel high, she could not sleep, and her mind was racing; Risperidone, gained much weight; Seroquel gained weight also. Klonopin: that seems to slow me down. The last one begins with an “L.” I do not remember, but that squashes me in creativity.
Allergies: No allergies stated to medication, food, or pollen.
Reproductive History: On birth control pills, denies being pregnant. Have regular menus. Being promiscuous, but declares being safe. Menses was last month sometime and would not give a specific date. Ms. P.P. identifies herself as a woman. Ms. P. states she has polycystic ovaries.
R.O.S.
General: The patient appears in good health, is height/ weight proportionate, she appears slightly older than she stated. Vital signs typical, no fever. No malaise or weight
HEENT: No blurred vision, visual loss, or yellow sclera. Ears, Nose, Throat: No hearing loss, nasal drainage/congestions, headaches, or sore throat.
SKIN: No wounds, flushing, rashes, redness, or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, difficulty breathing, cough, sputum, or cyanosis GASTROINTESTINAL: No anorexia, nausea, vomiting, diarrhea, or constipation. No abdominal pain or discomfort. No blood.
GENITOURINARY: No burning on urination, urgency, hesitancy, pain, or discomfort. Denies any odor or odd color in urine. No alteration in the bladder.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. The gate appears even and smooth.
MUSCULOSKELETAL: No muscle or joint pain, weakness, back pain, stiffness, or reduction of range of motion.
HEMATOLOGIC: No excessive bleeding, anemia, clotting, or bruising. LYMPHATICS: No enlarged painful nodes. No history of splenectomy ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance, hair loss, excess urination, fatigue, or polydipsia. She has thyroid issues.
OBJECTIVE:
Diagnostic results: Vital signs are within normal range: Temp: 98.2; Pulse: 90: Respiration: 18: Blood Pressure: 138/88. Laboratory Test: Urine drug and alcohol screen negative. CBC within normal ranges, CMP within normal ranges. Lipid panels are within normal ranges. Prolactin Levels 8; TSH 6.3 (H). The CMP and CBC can help determine the general health of the patient.
Still, TSH and PRL are necessary due to the relationship between reproductive hormones, thyroid disease, and depression in women. The prolactin is normal but on the low side. Hypothyroidism and medication can create Hypo- prolactinoma levels (Jacobson, 2012; Petruzzelli et al., 2020). TSH levels can cause an increased risk for readmission secondary to exacerbated depressive symptoms when thyroid disease is untreated (Yang et al., 2021).
Assessment:
Mental Status Examination:
The patient appears alert but not orientated. Ms. P. stated her birthday is July 1, 1995, and today’s date patient said December 1st, 2020, which makes her only five years old. Ms. P’s developmental age appears a lot older than that. She seems to be about 19 years of age, a Mexican American young woman who looks much older than her age. She is semi-cooperative. She is neatly groomed and clean and dressed appropriately.
There is no evidence of any abnormal motor activity. Her speech is clear, presently coherent during the interview, and standard in volume and tone. The thought process is incongruent with her goals directed and logic. Her logic was fair to poor, and insight was noted. Documented delusional thought process and pattern, but no AVH during the time of interview. Her mood is euphoric, and her affect appropriate to her spirit. There is some evidence of loss of association or flight of ideas. The patient’s eye contact is good; the patient’s body position is closed, with legs crossed in the chair.
Presently patient denies thoughts of suicide/self s harming but had thought in the past. She was chucking at inappropriate times. She denies any auditory or visual hallucinations at this time. Cognitively, she is alert and oriented. Her recent and remote memory is semi-intact all the way. She could not remember the drugs, dosage, and last time taken. Her hospitalization was unknown dates, where, and when or durations. Her concentration appears fair. Her insight is acceptable to the poor. She smokes and drinks, and she is highly promiscuous.
Diagnostic Impression:
The patient has multiple diagnoses. She does not meet all the criteria for Schizoaffective. According to American Psychiatric Association (2013), schizoaffective disorder is based on assessing an uninterrupted period of illness during which the individual continues to display active or residual symptoms of psychotic illness such as schizophrenia. She hears the voices when she is manic, and lacks sleep. There are some overlapping symptoms, but she does not meet all criteria (Baryshnikov et al., 2020).
She may meet the criteria for Bipolar Disorder with a introductory presentation of mania and depression (American Psychiatric Association, 2013). Manic has inflated self-esteem, decreased need for sleep, and flights of the idea. MDD is depression most of the day, insomnia, fatigue, feeling of worthlessness, or excessive or inappropriate guilt (Chen et al., 2021; Sadock et al., 2015). The third possible diagnosis is a personality disorder.
Diagnosis of borderline personality. It is a pattern of instability in interpersonal relationships, self-image and affects, and marked impulsivity (American Psychiatric Association, 2013; Bateman et al., 2015). She does meet these criteria because of the sexual risky behavior, instability interpersonal relationships, unstable self-image, self-cutting, and suicide attempts. This diagnosis will be deferred until it is collected and until other diagnoses are explored (Choukas-Bradley et al., 2020; Bateman et al., 2015).
Reflection:
In reflection on this case in question, questions regarding the extent, nature and frequency of her sexual risky behavior, suicide attempts, mania and depression . The trauma that occurred during her childhood needs to be further study and how it affected her. The information must differentiate between bipolar and personality disorder fully. Currently the behavior could point to personality disorder, specifically borderline personality, with a possible dual diagnosis of bipolar.
The hearing of voices comes when she’s manic and lack of sleep, which fits the diagnosis of bipolar. I do not think the schizoaffective disorder is the appropriate diagnosis. Medication is not first-line treatment, if she has borderline personality disorder. Psychosocial intervention is the primary treatment (Bateman et al., 2015). With comorbidity as in this case, Bipolar, medication would help and could be treated .
Case Formation and Treatment Plan
This Ms. P. tried so many medications and she has as a history of taking drugs and then stopping them; also, she has thyroid disease. My most significant concern is her risky behavior, mania, suicide attempts, and depression. Order labs and EKG to monitor the OT intervals, daily weight, Rapid plasma regains (RPR) and genetic marker for the family.
I would like to see a PCP to start her on Synthroid, plus considered Topiramate 50 mg B.I.D for mood and sleep (Stahl, 2017; Kantojarvi et al., 2020). Will slowly titrated medication up while assessing for side effects and efficacy over the next several months in an outpatient setting. The following medication would be Citalopram 20mg daily, which is a SSRI and S- RI, would use this for mood stabilization (Stahl, 2017; Onishi et al., 202; Kantojarvi et al., 2020). Will be slowly titrated up medication while assessing for side effects and efficacy over the next several months.
I would start therapy to explore the nature of her risky sexual behavior, her ineffective coping mechanism, and her instability interpersonal relationships. She will need support in identifying cognitive distortions, addressing stuck points in her trauma, creating a safety plan, and identifying positive coping skills. Ms. P. will have appointments for therapy and psychiatry services.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association.
Baryshnikov, I., Sund, R., Marttunen, M., Svirskis, T., Partonen, T., Pirkola, S., & Isometsä, E. T. (2020). Diagnostic conversion from unipolar depression to bipolar disorder, schizophrenia, or schizoaffective disorder: A nationwide prospective 15‐year register study on 43 495 inpatients. Bipolar Disorders. https://doi.org/10.1111/bdi.12929
Bateman, A. W., Gunderson, J., & Mulder, R. (2015). Treatment of personality disorder. The Lancet, 385(9969), 735–743. https://doi.org/10.1016/s0140-6736(14)61394-5
Case Study: Petunia Park. (2021). https://class.waldenu.edu.
Walden University Blackboard:
Chen, H., Li, W., Cao, X., Liu, P., Liu, J., Chen, X., Luo, C., Liang, X., Guo, H., Zhong, S., Wang, X., & Zhou, J. (2021). The Association Between Suicide Attempts, Anxiety, and Childhood Maltreatment Among Adolescents and Young Adults With First Depressive Episodes. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.745470
Choukas-Bradley, S., Hipwell, A. E., Roberts, S. R., Maheux, A. J., & Stepp, S. D. (2020). Developmental Trajectories of Adolescent Girls’ Borderline Personality Symptoms and Sexual Risk Behaviors. Journal of Abnormal Child Psychology, 48(12), 1649–1658. https://doi.org/10.1007/s10802-020-00699-4
CrashCourse. (2014). Depressive and Bipolar Disorders: Crash Course Psychology #30. On YouTube. https://www.youtube.com/watch?v=ZwMlHkWKDwM
Jacobson, S. A., & American Psychiatric Publishing. (2012). Laboratory medicine in psychiatry and behavioral science. American Psychiatric Pub.
Kantojärvi, L., Hakko, H., Mukka, M., Käyhkö, A., Riipinen, P., & Riala, K. (2020). Psychotropic medication use among personality disordered young adults. A follow-up study among former adolescent psychiatric inpatients. Psychiatry Research, 293, 113449. https://doi.org/10.1016/j.psychres.2020.113449
Onishi, Y., Mikami, K., Kimoto, K., Watanabe, N., Takahashi, Y., Akama, F., Yamamoto, K., & Matsumoto, H. (2021). Second-Generation Antipsychotic Drugs for Children and Adolescents. Journal of Nippon Medical School, 88(1), 10–16. https://doi.org/10.1272/jnms.jnms.2021_88-108
Petruzzelli, M. G., Marzulli, L., Giannico, O. V., Furente, F., Margari, M., Matera, E., & Margari, F. (2020). Glucose Metabolism, Thyroid Function, and Prolactin Level in Adolescent Patients With First Episode of Schizophrenia and Affective Disorders. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00775
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry (11th ed.). Wolters Kluwer.
Stahl, S.M. (2017). Essential Psychopharmacology: Prescriber’s Guide (6th.). University Printing House
Yang, L., Yang, X., Yang, T., Wu, X., Sun, P., Zhu, Y., Su, Y., Gu, W., Qiu, H., Wang, J., Chen, J., & Fang, Y. (2021). The effect of thyroid function on the risk of psychiatric readmission after hospitalization for major depressive disorder. Psychiatry Research, 305, 114205. https://doi.org/10.1016/j.psychres.2021.114205
Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing. Walden University.(2022). Minneapolis, Minnesota
To Prepare for NRNP6665 Week 4 Assessing, Diagnosing, and Treating Adults With Mood Disorders
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.