PRAC 6665 WEEK 7 FOCUSED SOAP NOTE AND PATIENT CASE PRESENTATION, PART 1  Subjective:

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CC (chief complaint):  “I’ve been feeling extremely energetic and haven’t been sleeping much, but sometimes I feel down and can’t get out of bed.”

HPI: S.L. is a 32-year-old male patient of German origin, presenting with a history of recurrent mood disturbances. He reports experiencing episodes of elevated mood, increased energy, decreased need for sleep, and heightened irritability, lasting for several days to weeks. These episodes are often followed by periods of profound sadness, loss of interest in activities, changes in appetite, and suicidal thoughts. The patient describes a pattern of mood swings impacting his work performance and interpersonal relationships.

Substance Current Use: The patient reports being an Occasional alcohol user but denies using illicit drugs.

  • Medical History: The patient was diagnosed with bipolar disorder at age 28, and he was previously hospitalized for manic episodes.
  • Current Medications: None currently, as the patient stopped taking medications six months ago.
  • Allergies: No known drug and food allergies.
  • Reproductive Hx: The patient is single and has no children.

ROS:

  • GENERAL: The patient has a stable weight and no fever or chills.
  • HEENT: The patient reports no headaches, vision changes, or hearing loss. The patient reports occasional nosebleeds related to cocaine use.
  • SKIN: There are no reported skin issues.
  • CARDIOVASCULAR: No edema or palpitations, chest discomfort, pain, or pressure.
  • RESPIRATORY: No shortness of breath or cough.
  • GASTROINTESTINAL: The patient has not experienced any gastrointestinal symptoms.
  • GENITOURINARY: The patient reports no genitourinary issues.
  • NEUROLOGICAL: The patient reported no headaches, dizziness, or seizures.
  • MUSCULOSKELETAL: The patient has no musculoskeletal complaints.
  • HEMATOLOGIC: No history of bleeding or bruising
  • LYMPHATICS: The patient reports no lymphatic problems.
  • ENDOCRINOLOGIC: No heat or cold intolerance, no polyuria or polydipsia.

 

Objective:

Diagnostic results: No new diagnostic tests were conducted. Previous diagnosis confirmed through clinical assessment and patient history.

Assessment:

Mental Status Examination: The patient is a 32-year-old German male. He is well-dressed and groomed. During the assessment, the patient is cooperative but appears restless and fidgety. The patient appears restless and agitated. He demonstrates pressured speech and exhibits a flight of ideas. Mood assessment reveals expansive affect, consistent with a manic episode. Physical examination is unremarkable, and vital signs are within normal limits.

 

Diagnostic Impression:

 

Bipolar Disorder: This is a mental health condition characterized by extreme mood swings that include emotional highs (mania or hypomania) and lows (depression) (McIntyre et al., 2020). These mood swings can affect sleep, energy levels, behavior, judgment, and the ability to think clearly. The patient exhibits a history of manic behavior. Previous hospitalizations for manic episodes and a family history of bipolar disorder further support this diagnosis. Current symptoms include alternating periods of elevated mood and severe depression; hence, bipolar disorder is the primary diagnosis. This diagnosis aligns with DSM-5-TR criteria and will ensure an accurate treatment plan and management.

 

Cyclothymic Disorder: Cyclothymic disorder, also known as cyclothymia, is a mood disorder characterized by chronic, fluctuating mood disturbances involving numerous periods of hypomanic symptoms and periods of depressive symptoms that are not severe enough to meet the criteria for a full hypomanic episode or major depressive episode (Bielecki & Gupta, 2020). However, Cyclothymic Disorder excludes the presence of any major depressive, manic, or hypomanic episodes that meet the criteria for other mood disorders (Zinno et al., 2020). While considered, Cyclothymic Disorder was deemed less likely due to the patient’s history of distinct manic episodes and severe depressive episodes that align more closely with Bipolar Disorder.

 

Major Depressive Disorder Major with Hypomanic Episodes: This is a mental health condition characterized by persistent and intense feelings of sadness and increased energy (Serretti et al., 2021). The patient reports episodes of major depression with occasional periods of elevated mood and increased energy, which do not reach the severity of full-blown mania. Major Depressive Disorder with Hypomanic Episodes was considered due to the patient’s depressive and hypomanic symptoms but was ruled out in favor of Bipolar Disorder, which better fits the patient’s history of severe manic episodes.

Reflections:

I agree with the preceptor’s assessment and diagnostic impression of Bipolar Disorder for the patient. The patient’s history of manic episodes, characterized by extreme energy, decreased need for sleep, and risky behavior, along with severe depressive episodes, aligns well with the DSM-5-TR criteria for Bipolar Disorder (Cafaro et al., 2023). The presence of full-blown manic episodes and alternating periods of depression strongly supports this diagnosis over other mood disorders, such as Cyclothymic Disorder or Major Depressive Disorder Major with Hypomanic Episodes. This case taught me the importance of a thorough and systematic approach to diagnosing mood disorders, especially in distinguishing between similar conditions. I understood the need for detailed patient history, careful symptom observation, and strict adherence to diagnostic criteria.

If faced with similar cases in the future, I would conduct a more detailed exploration of the patient’s psychosocial background, including work and personal relationships, lifestyle habits, and any recent life changes contributing to mood instability. I would also emphasize the importance of medication adherence and investigate potential barriers, such as side effects, beliefs about medication, or a lack of understanding of the disorder. To address comprehensive patient needs, I would implement a multidisciplinary approach involving collaboration with other healthcare providers, such as social workers and therapists. Finally, I would ensure that the need for involuntary treatment in severe episodes is assessed, fulfilling the duty to warn if the patient poses a risk to themselves or others and ensure the patient understands the necessity and side effects of medication. Respecting patient autonomy and adhering to the principles of non-maleficence and beneficence are also crucial to providing ethical and effective care.

Case Formulation and Treatment Plan:

After concluding the diagnosis, a suitable treatment plan was initiated. A Comprehensive Metabolic Panel and Thyroid Function Tests, urine toxicology, and an EKG should be carried out to rule out any underlying medical condition that might contribute to the patient’s symptoms. The patient was referred to a psychiatrist for medication management, a cognitive-behavioral therapy (CBT) therapist, and a case manager for assistance with social determinants of health (Nierenberg et al., 2023). Lithium was initiated at 300 mg twice daily for mood stabilization, with dosage adjustments based on blood level monitoring (Volkmann et al., 2020). Potential side effects, such as weight gain, tremors, polyuria, and thyroid and kidney dysfunction, were discussed with the patient. Lamotrigine was considered for depressive episodes, starting at 25 mg daily and titrating slowly to avoid rash and Stevens-Johnson syndrome. Selective serotonin reuptake inhibitors (SSRIs) were considered cautiously for depressive episodes to avoid triggering mania, with specific medication and dosage determined based on patient response and tolerability (Hashimoto et al., 2021). The patient was educated on the importance of medication adherence and the risks of abruptly stopping medication without consulting healthcare providers. The patient was advised on the risks of mixing prescribed medications with over-the-counter drugs, herbal supplements, alcohol, and illegal drugs and the importance of abstinence for mental health stability.

The initial follow-up was scheduled in one week to assess medication tolerance and initial response. Ongoing follow-ups were planned every two weeks, then monthly as the patient stabilized, with adjustments made based on symptom management and side effects. Collaborative reviews of hospital and therapist records were conducted regularly to ensure comprehensive care, and a Prescription Monitoring Program (PMP) report was reviewed periodically to ensure appropriate use of prescribed medications.

PRECEPTOR VERIFICATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

References

Bielecki, J. E., & Gupta, V. (2023). Cyclothymic Disorder. In StatPearls [Internet]. StatPearls Publishing.

Cafaro, R., Macellaro, M., Dell’Osso, B., & Suppes, T. (2023). Mixed Features in Bipolar Disorder: assessing symptoms profiles and their relation with DSM-5 criteria. European Psychiatry, 66(S1), S579-S579. https://doi.org/10.1192/j.eurpsy.2023.1210.

Published by Amilik