Bipolar 1
Subjective:
CC (chief complaint): “I argued with my family, and I punched some walls`”
HPI: T.C. is a 21 yo male admitted on 1013 for suicidal ideations and aggression. Pt admits to
punching some walls, injuring both his hands, and threatening to kill himself with a knife after an
argument with his brother. Pt is impulsive, agitated, irritable mood, aggressive, and anxious with
suicidal thoughts. Pt reports being on parole for fraud and identity theft. Pt reports sleep
disturbances and reports he has gone two days without sleep. Pt endorses smoking cannabis, and
he drinks alcohol 2-3 days out of the week. Pt denies any medical history or previous psych
diagnoses or hospitalization. Pt denies any self-harming behaviors or trauma, or abuse. Pt is
single, unemployed, and lives with his mother and sibling. Pt is mini-zing with poor insight and
poor judgment.
Substance Current Use: cannabis-everyday smoker,alcohol-2-3 drinks, three days a week,UDSpositive
for cannabis
Medical History:none
Current Medications: none
Allergies: NKDA
Reproductive Hx: NO congenital deformities reported
ROS:
GENERAL: cannabis abuse, impulsivity, agitation, mood swings, irritable mood, aggression
HEENT: denies headaches, no other neurological symptoms reported
SKIN: superficial abrasion to bilateral hands, denies rash, no pallor, capillary bed changes
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CARDIOVASCULAR: denies chest pain, palpitations, peripheral edema
RESPIRATORY: Denies wheezing, stridor, apnea, chest tightness, or chest tenderness
GASTROINTESTINAL: no abdominal pains; denies N/V/D, constipation, or blood in
stool/emesis
GENITOURINARY: denies hematuria, difficulty urinating, dysuria, no blood in the urine
NEUROLOGICAL: Denies dizziness, headaches, lightheadedness, syncope, tingling, or
numbness
MUSCULOSKELETAL: Denies arthralgia, myalgia, changes in gait, ROM, denies back pains
HEMATOLOGIC: Denies any bleeding problems or diagnosis
LYMPHATICS: Denies lymph node enlargements
ENDOCRINOLOGIC: Denies History of Immune deficiency or immunomodulating drugs
Objective:
Diagnostic results: uds-positive for cannabis, blood etoh level -37
The Young Mania Rating Scale (YMRS) is one of the most widely used rating scales to measure
mania symptoms.(Prisciandaro & Tolliver, 2016) The scale contains 11 items and is focused on
the client’s subjective report of his symptoms for the past 48 hours. The provider will assess
additional data by assessing during the clinical interview. Four core items are graded on a 0 to 8
scale, including irritability, speech, thought content, and disruptive/aggressive behaviors. The
other seven items are graded on a 0 to 4 scale. The four core items are heavily weighted and
range from poor cooperation to severely ill patients. The test can measure patients who are
acutely ill or can be used to measure mania symptoms sober for a period and can be completed
within 15-30 min. T.C. scored a 38 on the YMRS scale, which was congruent with his clinical
assessment. The YMRS can range up to 60 maximum scores with a Total score of ≤12,
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indicating remission (13-19=minimal symptoms; 20-25=mild mania, 26-37=moderate mania, 38-
60=severe mania).(Cerimele et al., 2019)
Assessment:
Mental Status Examination:21 yo male who presents as disheveled. Appropriately dressed for the
weather. Pt is alert and oriented x4. The Patient is anxious and agitated with labile affect. Speech
is regular rate and volume for age. The thought process is illogical, and the thought content is
appropriate. Pt reports suicidal ideations. Denies auditory or visual hallucinations. Pt reports no
one listens to him, and he is better off not being here anymore. Pt is swaying back and forth
during the interview, and he has irritability, mood swings, impulsivity, agitation, and difficulty
concentrating and focusing. Memory is intact, with poor insight and poor judgment.
Diagnostic Impression:
F31.1 Bipolar one manic, severe w/o psychosis
According to DSM-5-TR, Bipolar one is characterized by a distinct period of abnormally and
persistently elevated, expansive, or irritable mood, goal-directed activity, or energy lasting at
least one week and present most of the day. (Association, 2022)During the period of mood
disturbance, patients exhibit inflated self-esteem, decreased need for sleep, talkative more than
usual, flight of ideas, distractibility, and increased goal-directed activity. This Patient has
decreased need for sleep with irritable mood, impulsivity in punching the walls after an argument
and grabbing a knife, and threatening to kill himself because he felt unheard by his family.
F33.2 MDD severe w/o psychotic features
According to DSM-5-TR, MDD involves five or more symptoms of depressed mood, sadness,
emptiness, hopelessness, irritable moods, insomnia, loss of energy, and diminished ability to
think all day every day for at least two weeks. (Association, 2022)T.C. reported irritable moods,
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energy loss, and sadness regarding legal issues and his family not supporting him.
F90.9 Attention-deficit/hyperactivity disorder
According to DSM-5-TR, ADHD is often misdiagnosed as bipolar, mainly in children and
adolescents. Many symptoms counteract each other such as mania, rapid speech, distractibility,
and decreased need for sleep(Association, 2022). J.C. exhibited manic behaviors and impulsivity
during the interview and endorsed difficulty concentrating and focusing.
Reflections:
Bipolar one disorder is a complicated group of debilitating and long-standing disorders that has
several components bipolar I disorder and bipolar II disorder. These subsets can be defined as
manic, hypomanic, or depressed types. Research has shown that individuals who have Bipolar
disorders can have considerable troublesome psychosocial functioning that has been connected
to a loss of roughly 10-20 potential years of life. (Cerimele et al., 2019) Bipolar disorder has a
substantial genetic transferability of approximately 70%. Bipolar I is closely genetically
connected to schizophrenia, as bipolar II is relatively close to major depressive
disorder.(Cerimele et al., 2019) The cause of bipolar disorders is yet to be known, but studies
have found disturbances in neuronal-glial plasticity, monoaminergic signaling, inflammatory
homeostasis, and mitochondrial operations. Also, childhood maltreatment is highly linked to
bipolar disorders. The gold standard treatment for Bipolar is lithium has been found to reduce
mania, depression, and suicidal behaviors drastically. The treatment drug I chose for this Patient
is Zyprexa 5mg po q am and 5mg po @ hs. Olanzapine is an antipsychotic that can treat bipolar
and schizophrenia by reducing the dopamine and serotonin levels in the brain. (McIntyre et al.,
2020)The social determinants of health that patients with Bipolar face are reduced employment
opportunities, educational performance, and secure housing.(Alegría et al., 2018)One education
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strategy for patients with Bipolar disorder is to recommend community-based resources such as
individual support placement and housing-first programs that help locate housing and
employment opportunities. Ethical issues faced with caring for mentally ill patients is not to
harm. As a provider, we must stay knowledgeable about our mental health clients’ new and latest
treatment options. Also, we have to protect our Patient’s rights regarding informed consent and
confidentiality with treatment plans. (Bipeta, 2019)
Case Formulation and Treatment Plan:
The treatment plan I recommend for this Patient is as follows:
1.) Patient will remain admitted to Psychiatric Hospital for acute stabilization as inpatient
psychiatric hospitalization is the least restricted setting. Medical decision-making is HIGH.
2.) Patient will be assessed by the psychiatric provider daily.
3.) An H and P to be conducted to identify any underlying medical conditions or illnesses.
4.) Patient will be placed on suicide precautions with q15min safety checks.
5.) Patient to have Q5minute checks while in the milieu
6.) Further diagnostic workup: a. Routine labs (CBC, CMP, TSH, Lipid Panel, HbA1C, drugs
screens, etc.) are pending and reviewed to aid further diagnostic workup. b. Treatment planning
with the collaborative team is to be started as early in the treatment course. Ongoing treatment
planning and collaboration with a unit therapist will maximize further diagnostic workup.
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: __________________________
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______________________________ Date: ________________________ NRNP/PRAC 6675
Focused SOAP Psychiatric Evaluation
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References
Alegría, M., NeMoyer, A., Falgàs Bagué, I., Wang, Y., & Alvarez, K. (2018). Social
determinants of mental health: Where we are and where we need to go. Current
Psychiatry Reports, 20(11). Retrieved July 12, 2023, from
https://doi.org/10.1007/s11920-018-0969-9
Association, A. P. (2022). Diagnostic and statistical manual of mental disorders, fifth edition,
text revision (dsm-5-tr(tm)) (5R ed.). American Psychiatric Association Publishing.
Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of
Psychological Medicine, 41(2), 108–112. Retrieved July 12, 2023, from
https://doi.org/10.4103/ijpsym.ijpsym_59_19
Cerimele, J. M., Goldberg, S. B., Miller, C. J., Gabrielson, S. W., & Fortney, J. C. (2019).
Systematic review of symptom assessment measures for use in measurement-based care
of bipolar disorders. Psychiatric Services, 70(5), 396–408. Retrieved July 10, 2023, from
https://doi.org/10.1176/appi.ps.201800383
McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L., Malhi,
G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., Young, A.
H., & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841–1856.
Retrieved July 12, 2023, from https://doi.org/10.1016/s0140-6736(20)31544-0
Prisciandaro, J. J., & Tolliver, B. K. (2016). An item response theory evaluation of the young
mania rating scale and the montgomery-asberg depression rating scale in the systematic
treatment enhancement program for bipolar disorder (step-bd). Journal of Affective
Disorders, 205, 73–80. https://doi.org/10.1016/j.jad.2016.06.062
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