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:

· General Statement: No prior diagnoses or care-seeking

· Caregivers (If Applicable): None

· Hospitalizations: Recent (2024)

· Medication 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).

References

Arnold, I., Dehning, J., Grunze, A., Haussmann, A. (2021). Old age bipolar disorder:

Epidemiology, etiology, and treatment. Medicina, 57(5), DOI:

10.3390/medicina57060587

Citrome, L. (2021). Olanzapine: chemistry, pharmacodynamics, pharmacokinetics, and

metabolism, clinical efficacy, safety, and tolerability. Expert Opinions on Drug

Metabolism and Toxicology, 9(2), DOI: 10.1517/17425255.2018.759211

E. L. Yearwood & V. P. Hines-Martin (2016). Routledge handbook of global

mental health nursing: Evidence, practice and empowerment (pp. 200–212).

 

Routledge/Taylor & Francis Group

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, DOI: 10.1186/s12991-021-

00367

Novick, D., Swartz, H. (2019). Evidence-based psychotherapies for bipolar disorder.

Focus: The Journal of Lifelong Learning in Psychiatry, 19, DOI:

10.1176/appi.focus.2010004

Soltis-Jarrett, V. (2017). Strategies for health promotion in individuals experiencing.

bipolar symptoms and illness.

PRECEPTOR VERFICIATION:

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.

Preceptor signature: ________________________________________________________

Date: ________________________

Provide a response to the below questions according to the assessment completed from your collegue. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.

What safety precautions should be implemented to reduce potential risks associated with the symptoms of late Bipolar I disorder in an older adult?
How would you prioritize the interventions for an older adult individual diagnosed with Bipolar I disorder?
How does the age and developmental stage of the patient affect the onset and treatment of Bipolar I disorder symptoms?

NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation Template

Safety precautions are crucial to reduce potential risks associated with late Bipolar I disorder in an older adult like Mr. James. Given his recent manic episode and symptoms of paranoia and aggression, it’s essential to implement measures to ensure his safety and the safety of those around him. Firstly, it’s imperative to remove any potential hazards from his environment, such as sharp objects or items that could be used for self-harm or harm to others. Mr. James may benefit from close supervision, especially during periods of heightened agitation or delusional thinking. Consider implementing a buddy system where his wife or another trusted individual can keep an eye on him to prevent impulsive or risky behaviors. Additionally, developing a crisis intervention plan that outlines steps to take in the event of a manic episode or suicidal ideation is essential for Mr. James’ safety. This plan should include contact information for emergency services, crisis hotlines, and mental health professionals who can provide assistance when needed.

 

Prioritizing interventions for Mr. James involves addressing his immediate safety concerns while also focusing on long-term management of his Bipolar I disorder. Given his recent manic episode and the risk of future relapse, ensuring medication adherence is paramount. Collaborate with Mr. James and his wife to develop strategies for medication management, such as setting up pill organizers, using reminder apps, or involving a family member in medication administration. Psychoeducation about the importance of medication compliance and early recognition of warning signs of relapse should be provided to both Mr. James and his wife. Additionally, engaging Mr. James in regular therapy sessions, such as cognitive-behavioral therapy (CBT) or psychoeducation groups, can help him develop coping skills and improve insight into his condition.

 

The age and developmental stage of the patient significantly affect the onset and treatment of Bipolar I disorder symptoms. In older adults like Mr. James, late-onset Bipolar I disorder may present differently than in younger individuals. Age-related changes in brain structure and function, as well as comorbid medical conditions, can complicate the diagnosis and management of Bipolar I disorder in older adults. Additionally, older adults may be more susceptible to medication side effects and drug interactions, requiring careful monitoring and dose adjustments. Developmental factors, such as life transitions or retirement, may also contribute to the onset or exacerbation of Bipolar I disorder symptoms in older adults. Therefore, treatment approaches should be tailored to address the unique needs and challenges faced by older individuals with Bipolar I disorder, taking into account their medical history, cognitive function, and social support network.

 

References:

 

Novick, D., & Swartz, H. (2019). Evidence-based psychotherapies for bipolar disorder. Focus: The Journal of Lifelong Learning in Psychiatry, 19. doi:10.1176/appi.focus.2010004

 

Soltis-Jarrett, V. (2017). Strategies for health promotion in individuals experiencing bipolar symptoms and illness.

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