Comprehensive Focused Soap Psychiatry

Removednrnpprac 6665 6675 Comprehensive Focused Soap Psychiatric

[Removed] NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template Week 9: Complex Case Study Presentation June James College of Nursing-PMHNP, Walden University PRAC 6675: PMHNP Care Across the Lifespan II April 24, 2024 Subjective: CC (chief complaint): “I was doing poorly last week, but I feel better now.†HPI : The patient is a 65-year-old Asian American male who is presenting for follow up care after a visit to the emergency room in which chemical restraint was required. The patient was diagnosed with late-onset bipolar I disorder. He was taking lithium and olanzapine to manage symptoms. However, his wife indicates that he has increasingly missed doses in the six weeks before experiencing a manic episode that required brief hospitalization. Symptoms are characterized by wide variations in clinical manifestations, including several weeks with no signs or symptoms of depressive episodes followed by one week of acute elevated mood, heightened energy, and grandiose thinking. His medical history is noteworthy for hyperlipidemia and hypertension. He has no prior history of substance use or alcohol abuse. He also has no previous history of psychotic symptoms but was diagnosed with major depressive disorder at age 33. However, he was in denial and refused treatment at that time. His wife presents for care with him and states that his symptoms began to appear approximately five and a half years ago, when he changed jobs after two decades working as a professor. She describes symptoms as including reduced need for sleep, hyperactivity, excessive talkativeness, and aggression toward others. She describes an excessive desire to make repairs in and around their home. She also describes a verbal altercation with a neighbor that briefly became physical and led to the police having to be called. She also describes grandiose and persecutory thinking about his current job, in which he supervises a small research team. She says that he has stated repeatedly that his team members are out to get him because they are jealous of his expertise. She indicates that symptoms increased suddenly and dramatically in the days before his emergency room visit, including his repeated statements that his research team members have installed cameras in his home to place him under surveillance and eventually to kidnap him. Past Psychiatric History : · G eneral Statement: No prior diagnoses or care-seeking · C aregivers (If Applicable): None · H ospitalizations: Recent (2024) · M edication Trials: None Psychotherapy or Previous Psychiatric diagnosis: MDD in 1991 Substance Current Use and History: Denies drugs and alcohol usage. Smoked cigarettes on and off in stressful times, no more than a pack a month. Family Psychiatric History: Patient reported his maternal grandmother had a history of depression and questionable-undiagnosed bipolar due to her mood swings. Psychosocial History: He supervises a small research team since he stopped working as a professor. He is married and lives with his wife. He has three children and two grandchildren. Medical History: · Current illness: He was diagnosed with bipolar I disorder in 2019. His diagnosis was provided after receiving a CT scan, EEG and MRI. Testing at that time also included CMP, thyroid function, and lipid profile. Prehypertension and hyperlipidemia, both of which he was diagnosed with in 2019. He was also diagnosed with MDD in 1991. · Current Medications : lithium 400mg PO daily and olanzapine 5mg PO daily · Allergies : tree nuts and seasonal pollen · Reproductive Hx : None ROS : · GENERAL: he presents with good hygiene and signs of self-care · HEENT: denies headache and fever; denies vision/hearing changes. · SKIN: denies rash and lesion · CARDIOVASCULAR: denies arrhythmia and palpitation; denies peripheral edema · RESPIRATORY: denies cough and wheezing · GASTROINTESTINAL: denies abdominal pain and nausea · GENITOURINARY: denies urgency and frequency · NEUROLOGICAL: denies tingling and numbness · MUSCULOSKELETAL: denies joint pain and swelling · HEMATOLOGIC: denies easy bruising · LYMPHATICS: denies swelling Objective: Diagnostic results : BP 130/80 mmHg, HR 76 bpm, RR 16 bpm, Temp 98.6°F Pain 0/10 Ht 5’9 Wt 175Ibs. The patient was administered the Mood Disorder Questionnaire, yielding a score of 10. The patient is identified with the presence of symptom clusters and serious problems from current symptoms. Assessment: Mental Status Examination: patient exhibits good hygiene and is dressed appropriately for the occasion. He describes persecutory and grandiose beliefs about others being out to get him. His speech patterns are pressured and tangential at times but coherent at other times. His recent and remote memory are good. Insight and judgment are grossly impaired. He demonstrates the ability to concentrate and above-average depth of knowledge. His mood is euthymic but emotionally labile; affect is agitated and distractible at times. He exhibits no evidence of gait imbalance or psychomotor agitation. Recent and remote memory are good. Diagnostic Impression: Bipolar I disorder is the likely diagnosis for this patient based on statements made by his wife and based on his prior hospitalization. In addition, the results of MDQ are indicative of this disorder. While the patient has denied recent depressive symptoms, he does have a past history of MDD and may not be sensitive to the presence of depressive symptoms. His wife does describe periods in which he sleeps excessively and does not interact with his family. Manic episodes for this patient are characterized by grandiosity, aggressive behavior, and hyperactivity. There is no way to account for these symptoms based on substance use or underlying medical condition. It is important to note that late-onset bipolar diagnosis is relatively rare, which may be one reason that he has not previously received this diagnosis in spite of presenting for annual wellness visits and interacting with physicians on multiple occasions in recent years. Differential diagnosis: · Bipolar I disorder (F31.1): diagnostic criteria for this disorder include at least one manic episode that is preceded or followed by hypomanic or depressive episodes. Manic episodes include a distinct period of abnormally and persistently elevated, irritable, or expansive mood that lasts at least one week. Manic episodes include inflated self-esteem or grandiosity, flight of ideas or racing thoughts, excessive talkativeness, distractibility, and increasing goal-directed activity (Ljubic et al., 2021). Mood disturbance cannot be attributable to physiological effects of a substance and episode cannot be better explained by another mental health disorder (Ljubic et al., 2021). This is the proper diagnosis for this patient. · Bipolar II disorder (F31.81): this condition is characterized by recurrent episodes of major depression and hypomania without full manic episodes. Hypomanic episodes include attributes of mania without symptom presentation that is severe enough to cause marked impairment in social or occupational functioning or which would not require hospitalization (Arnold et al., 2021). In this case, the patient has already demonstrated the need for an ER visit, which rules out this condition. · Major depressive disorder (F32.9): patients would exhibit depressive episodes without associated or concurrent mania. Symptoms would include hopelessness, fatigue, anhedonia, low self-worth, change in appetite or weight, sleep disturbance, or social isolation. These are not defining attributes of this case. Reflections: This case is noteworthy because it represents an example in which a diagnosis should not be ruled out based on demographic features of the patient. A patient at this age rarely receives a diagnosis of bipolar disorder. According to Arnold et al. (2021), approximately 5% of all bipolar cases involved diagnosis after the age of 50. Symptoms for this patient have appeared as a response to specific factors. For example, his symptoms emerged after changing jobs in 2019. They reemerged over the past six weeks after he began to abandon his medications. Another important attribute of this case is the need to assess factors that may have contributed to him abandoning his medication. It would also be necessary to evaluate the presence of social support resources and other factors that may help him adhere to treatment in the future. This might include telehealth appointments, medication reminders, and mobile applications that could help him avoid future abandonment of treatment. Coordinating services may be helpful because of the need to implement a multi component treatment plan that would be designed to prevent further manic episodes. Case Formulation and Treatment Plan: In this case and due to the complexities of bipolar disorder in an older adult, it is likely that the patient should be switched from lithium to valproic acid. Valproate 500mg PO daily and olanzapine 10mg PO daily is the recommendation in this multifaceted treatment plan. Valproate is generally perceived as being more effective as an anti-mania medication (Gergel & Owen, 2019). The patient should be kept on olanzapine because it is a first-line approach for long term maintenance of bipolar symptoms (Gergel & Owen, 2019). Valproate and olanzapine have been used effectively for mitigating symptoms of mania with psychotic features, particularly for older adults (Citrome, 2021). Information and referral to counseling with cognitive behavioral therapy focus would be provided. This would help the patient to identify his triggers and to learn new and effective coping skills. There is no need to evaluate drug interactions, particularly with hypertensive agents. This is true because the patient has not been taking medication for his prehypertension, and instead he has been managing symptoms with his diet and exercise. Health Promotion Recommendations : The patient must maintain regular sleep patterns by following good sleep hygiene, a healthy balanced diet, exercise, and adhere to the recommended medication regiment (Soltis-Jarrett, 2017). Additionally, mood journaling, social-rhythm therapy, CBT and regular visits to bipolar treatment specialists can support the patient in daily management of symptoms (Yearwood & Hines-Martin, 2016).

Paper For Above instruction

Introduction

Bipolar disorder, particularly bipolar I, presents unique diagnostic and management challenges, especially in older adults. Despite being traditionally viewed as a disorder affecting young adults, evidence suggests that bipolar disorder can manifest later in life, necessitating a tailored approach to assessment and treatment. This paper explores a complex case of late-onset bipolar I disorder in a 65-year-old male, highlighting diagnostic considerations, differential diagnoses, and an individualized treatment plan that addresses the unique aspects of bipolar disorder in older populations.

Case Overview and Clinical Presentation

The patient is a 65-year-old Asian American male presenting after a recent emergency room visit due to manic behaviors requiring chemical restraint. His history reveals prior episodes of major depressive disorder and a diagnosis of bipolar I disorder established in 2019 based on clinical evaluation and diagnostic testing, including neuroimaging. His symptoms, characterized by manic features such as grandiosity, hyperactivity, reduced need for sleep, agitation, and persecutory beliefs, are episodic and have fluctuated over the past five years, often triggered by significant life changes such as a career transition in 2019 and medication non-adherence in recent weeks.

Diagnostic Considerations

Diagnosing bipolar disorder in older adults involves careful consideration of age-related factors. Although bipolar I disorder is less common to be diagnosed after age 50, studies show that late-onset cases account for approximately 5% of bipolar diagnoses (Arnold et al., 2021). The patient's presentation aligns with DSM-5 criteria for bipolar I, with at least one manic episode evidenced by elevated mood, grandiosity, and hyperactivity lasting over a week. The absence of mood symptoms solely within a depressive episode, along with the episodic nature of symptoms, supports this diagnosis, differentiating it from bipolar II disorder and major depressive disorder.

Differential Diagnosis

While bipolar I is the primary diagnosis, other conditions must be considered. Bipolar II disorder is less likely given the patient's need for hospitalization during manic episodes, which suggests a more severe mania rather than hypomania (Arnold et al., 2021). Major depressive disorder is excluded because the patient exhibits prominent manic symptoms, and episodes of depression are not recent or prominent. Substance-induced mood disorders are also unlikely due to denial of substance use and unaltered medical conditions explaining mania. The differential diagnosis thus underscores the importance of thorough history-taking and clinical evaluation.

Implications of Late-Onset Bipolar Disorder

Late-onset bipolar disorder is relatively rare but significant, often associated with neurodegenerative processes, cerebrovascular disease, or medical comorbidities (Arnold et al., 2021). Its presentation may differ from early-onset cases, with more prominent paranoid or persecutory delusions, as seen in this patient. Factors such as life stressors, medication non-adherence, and comorbid conditions influence the course and treatment response. Recognizing late-onset bipolar disorder is crucial for avoiding misdiagnosis and providing appropriate management tailored to the older adult population.

Management Strategies

The treatment plan for this patient involves medication adjustment and psychosocial interventions. The initial approach recommends replacing lithium with valproic acid, owing to evidence suggesting better anti-manic efficacy in older adults and a favorable side effect profile (Gergel & Owen, 2019). The plan continues olanzapine at an increased dose for maintenance, as it is effective for controlling manic symptoms and psychotic features (Citrome, 2021). Polypharmacy considerations are vital, given the patient's age and comorbidities; hence, drug interactions and side effects must be carefully monitored.

The importance of psychoeducation, including counseling focused on cognitive behavioral therapy (CBT), cannot be overstated. CBT assists patients in identifying triggers and developing coping skills to manage symptoms effectively. Furthermore, social support systems and adherence facilitation—such as telehealth, medication reminders, and mobile health applications—are integral to maintaining stability and preventing relapse (Soltis-Jarrett, 2017).

Health Promotion and Patient Education

Effective management of bipolar disorder in older adults requires lifestyle modifications. Maintaining regular sleep schedules, engaging in routine physical activity, adhering to medication regimens, and practicing good nutrition are foundational health promotion strategies (Yearwood & Hines-Martin, 2016). Mood journaling and social-rhythm therapy can help monitor symptoms and promote stability by reinforcing daily routines and social engagement, which are protective factors against mood episodes (Soltis-Jarrett, 2017).

Conclusion

This case exemplifies the complexities of diagnosing and managing bipolar I disorder in late life. Despite its rarity in older adults, late-onset bipolar disorder warrants careful evaluation to distinguish it from other psychiatric and medical conditions. An individualized treatment approach, combining medication adjustments and psychosocial interventions, is essential for optimizing patient outcomes. Recognizing the influence of age-related factors and medical comorbidities enhances clinical decision-making and supports sustained mood stability in this vulnerable population.

References

• Arnold, I., Dehning, J., Grunze, A., Haussmann, A. (2021). Old age bipolar disorder: Epidemiology, etiology, and treatment. Medicina, 57(5). https://doi.org/10.3390/medicina
• Citrome, L. (2021). Olanzapine: Chemistry, pharmacodynamics, pharmacokinetics, and metabolism, clinical efficacy, safety, and tolerability. Expert Opinions on Drug Metabolism and Toxicology, 9(2). https://doi.org/10.1517/.2018.759211
• Gergel, T., Owen, G. (2019). Fluctuating capacity and advance decision-making in bipolar affective disorder: Self-binding directives and self-determination. International Journal of Law & Psychiatry, 40(2), 92-101.
• Ljubic, N., Ueberberg, B., Grunze, H. (2021). Treatment of bipolar disorders in older adults: A review. Annals of General Psychiatry, 20. https://doi.org/10.1186/s12991-021-00326-6
• Novick, D., Swartz, H. (2019). Evidence-based psychotherapies for bipolar disorder. Focus: The Journal of Lifelong Learning in Psychiatry, 19. https://doi.org/10.1176/appi.focus
• Soltis-Jarrett, V. (2017). Strategies for health promotion in individuals experiencing bipolar symptoms and illness.
• Yearwood, E. L., Hines-Martin, V. P. (2016). Routledge handbook of global mental health nursing: Evidence, practice, and empowerment. Routledge/Taylor & Francis Group.