NRNP 6665 PMHNP Across the Lifespan I: Assessing, Diagnosing, and Treating Adults With Mood Disorders -Comprehensive SOAP Note for Petunia Park Case Study

NRNP 6665 PMHNP Across the Lifespan I: Assessing, Diagnosing, and Treating Adults With Mood Disorders -Comprehensive SOAP Note for Petunia Park Case Study

NRNP 6665 PMHNP Across the Lifespan I Assessing, Diagnosing, and Treating Adults With Mood Disorders -Comprehensive SOAP Note for Petunia Park Case Study

Subjective:

CC (chief complaint): “I am here for a mental health assessment.”

HPI:

Petunia Park is a 27-year-old female client who presents for a mental health assessment. She mentions that she has a history of taking medications and failing to adhere to them because she thinks she does not need them. She feels that the meds squash her. Petunia also states that she has a history of falling into depression 4-5 times annually, which limits her from working at her aunt’s bookstore. When depressed, she sleeps a lot and has little to no motivation. She states that she lacks creativity when depressed leaving her feeling worthless. The depression comes after working hard for about five days on things she enjoys, like painting, writing, and music. Although people perceive that she has depression, Petunia thinks the sleepiness and lack of motivation are due to fatigue after several days of working hard.

Petunia reports that she is usually creative roughly a week before crushing. On her creative days, she declines to take her meds because they crush her and the lots of energy she has. She also sleeps for a few hours, does a lot of work, talks a lot, and seems scattered. Furthermore, the client reports engaging in sexual activity to explore her body and mind and get gratification. She is too busy to have meals when on the creative episodes but can eat everything when she crashes. She sleeps three hours a week when creative and 12-16 hours/per day when crushed. In addition, the client reports that when she has an inadequate sleep, she hears voices telling her that she is great and talented.

Substance Current Use: The last alcohol consumption was at 19 years. She admits to smoking 1PPD. She once used Marijuana, but it caused paranoia.

Medical History: Positive for Hypothyroidism

Current Medications: Levothyroxine for Hypothyroidism; and Hormonal pills for Polycystic Ovaries.
Allergies: None

Reproductive Hx: Has Polycystic Ovaries.

ROS:

GENERAL: Positive for increased appetite and low energy levels when depressed. Suppressed appetite and increased energy levels on creative episodes.
HEENT: Denies headache or eye, ear, nose, and throat symptoms.
SKIN: Denies skin symptoms.
CARDIOVASCULAR: Negative for cardiac symptoms.
RESPIRATORY: Negatives for difficulties in breathing.
GASTROINTESTINAL: Negative for abdominal distress.
GENITOURINARY: Negative for urinary symptoms.
NEUROLOGICAL: Denies paralysis, headaches, or loss of consciousness.
MUSCULOSKELETAL: Denies muscle, joint, or bone symptoms.
HEMATOLOGIC: Denies bleeding.
LYMPHATICS: Denies lymphatic symptoms.
ENDOCRINOLOGIC: Denies endocrine symptoms.

Objective:

Diagnostic results: No lab tests were ordered.

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Assessment:

Mental Status Examination: Female patient in her 20’s. She is neat and dressed appropriately for the function and weather. The client is alert and oriented and maintains adequate eye contact. Her speech is clear with normal rate and volume and logical. She demonstrates a coherent and logical thought process. Auditory hallucinations were reported, and delusions of grandeur were noted (states that she paints like Picasso and will sell paintings to movie stars). No evident suicidal ideations or thoughts. Her memory is intact, she demonstrates good judgment, and insight is present.

Diagnostic Impression:

Bipolar Disorder: Bipolar disorder presents with episodes of mania that alternate with depression. Petunia has manic episodes,

NRNP 6665 PMHNP Across the Lifespan I Assessing, Diagnosing, and Treating Adults With Mood Disorders -Comprehensive SOAP Note for Petunia Park Case Study

which she refers to as creative episodes, which alternate with depressive episodes, whereby she feels crushed. She presents with clinical manifestations consistent with the DSM-V diagnostic criteria for mania, including a decreased need for sleep, more talkative than usual, grandiosity, distractibility, increase in goal-directed activity, and engagement in activities with a high potential for adverse consequences like engaging in sexual activity for gratification (APA, 2013). The patient’s manic episodes alternate with depressed episodes, where she has low motivation, low energy levels, hypersomnia, and increased appetite (Vieta et al., 2018).

Major Depression: Major depression is a mood disorder that manifests with a depressed mood and significantly diminished interest/pleasure in almost all activities (APA, 2013). Petunia reports having depression episodes where she lacks the motivation to engage in activities she enjoys, like painting, writing, and music. In addition, she has clinical manifestations that meet the criteria for major depression, like hypersomnia, low energy levels, increased appetite, feelings of worthlessness, and decreased concentration (Christensen et al., 2020). This makes Major Depression a differential diagnosis. However, the patient also has manic episodes, making this a less likely primary diagnosis.

Schizophrenia: Schizophrenia presents with at least two of the following for not less than one month period: Delusions, Hallucinations, Disorganized speech, Grossly disorganized or catatonic behavior, and Negative symptoms (APA, 2013). Negative symptoms include diminished emotional expression, reduced motivation, poverty of speech, decreased emotional range, and diminished interests and drive (McCutcheon et al., 2020). Petunia presents with features consistent with schizophrenia, like auditory hallucinations (hears voices telling her that she is great and talented), delusions of grandeur, and negative symptoms such as lack of motivation and reduced interest and drive.

Reflections: When completing this assessment, I have learned that when diagnosing Bipolar disorder, the patient must meet the criteria for a manic episode, usually preceded by or followed by a major depressive episode. I have also learned that mood disturbance in Bipolar disorder is usually severe to cause significant impairment in social or occupational functioning. In a different situation, I would assess the patient for alcohol and substance abuse, which often presents as either mania or depression (Vieta et al., 2018). The mental health practitioner must consider the ethical duty to promote good and prevent patient harm by implementing treatment interventions supported by best practices. Furthermore, the practitioner should consider the patient’s level of income and insurance status when determining the treatment intervention. Health promotion should focus on practicing a healthy lifestyle in terms of diet and physical exercises to promote overall good health (Vieta et al., 2018).

Case Formulation and Treatment Plan:

The patient presents with clinical features consistent with Bipolar disorder- Mania. Treatment will comprise outpatient pharmacological therapy and psychotherapy.

Pharmacotherapy:  Quetiapine (extended-release) Day 1: 300 mg orally once daily; Day 2: 600 mg orally once daily; Maintenance dose of 400 mg/day orally.

Quetiapine monotherapy is recommended for mild to moderate mania in patients not requiring hospitalization. It is indicated in the acute treatment of manic episodes related to Bipolar disorder (Vieta et al., 2018).

Psychotherapy: The patient will be started on Cognitive behavior therapy (CBT) to help her recognize and modify maladaptive beliefs, thoughts, and behaviors that contribute to and worsen the manic symptoms. Novick & Swartz (2019) explain that CBT for bipolar disorder is based on the hypothesis that feelings, thoughts, and behaviors are interrelated and that changes in mood and cognitive processes during affective episodes influence behavior, which contributes to a vicious cycle that leads to the burden of the disease.

Follow-up: The patient will be scheduled for a follow-up after four weeks to assess her response to treatment, assess for medication, and modify the drug therapy if needed.

NRNP 6665 PMHNP Across the Lifespan I: Assessing, Diagnosing, and Treating Adults With Mood Disorders -Comprehensive SOAP Note for Petunia Park Case Study References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Christensen, M. C., Wong, C. M. J., & Baune, B. T. (2020). Symptoms of major depressive disorder and their impact on psychosocial functioning in the different phases of the disease: do the perspectives of patients and healthcare providers differ?. Frontiers in Psychiatry, 11, 280. https://doi.org/10.3389/fpsyt.2020.00280

McCutcheon, R. A., Reis Marques, T., & Howes, O. D. (2020). Schizophrenia-An Overview. JAMA psychiatry, 77(2), 201–210. https://doi.org/10.1001/jamapsychiatry.2019.3360

Novick, D. M., & Swartz, H. A. (2019). Evidence-based psychotherapies for bipolar disorder. FOCUS, A Journal of the American Psychiatric Association, 17(3), 238-248. https://doi.org/10.1176/appi.focus.20190004

Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., Gao, K., Miskowiak, K. W., & Grande, I. (2018). Bipolar disorders. Nature reviews. Disease primers, 4, 18008. https://doi.org/10.1038/nrdp.2018.8

Vieta, E., Salagre, E., Grande, I., Carvalho, A. F., Fernandes, B. S., Berk, M., … & Suppes, T. (2018). Early intervention in bipolar disorder. American Journal of Psychiatry, 175(5), 411-426.https://doi.org/10.1176/appi.ajp.2017.17090972

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