NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders

Subjective:

CC (chief complaint): Allegations by the patient’s mother that the patient recurrently gets moody this time of the year every year.

HPI: Ms. Julie Houston is a 19-year-old female who came to the psychiatric clinic for assessment following a recommendation from her mother. The patient presented with allegations by her mother that she recurrently gets moody around this time of the year annually. She reports that she is not feeling great and feels down. She admits to not doing so well, especially with her special business program in school. She reports that she comprehends everything but the classes are boring. She feels the teachers are stressing her with projects such as developing a mock company which she is finding difficult to complete. Two of the projects are already long overdue. The patient reports difficulty concentrating. For instance, she can read newspaper headlines and cannot seem to recall them almost immediately, a similar case with her classes. The patient has recently gained weight approximately ten pounds. She is experiencing excessive daytime sleepiness to an extent of sleeping through five of her classes this month. Initially, the patient was social, and easily made a lot of friends with whom she enjoyed their company. She would attend concerts and shows with them and engage in fun activities. However, lately, she finds them annoying, and dull and avoids their company. She currently prefers staying indoors alone which she partly attributes to the cold weather. She expresses her dislike for fall and winter because she cannot engage in activities such as going to the beach and riding in convertibles which she usually does during summer. She associates winter with darkness, and misery as opposed to beauty during summer.

Past Psychiatric History:

General Statement: The patient denies any past psychiatric treatment.
Caregivers (if applicable): Her parents.
Hospitalizations: The patient has never had any psychiatric admissions.
Medication trials: She is not on any medication trials.
Psychotherapy or Previous Psychiatric Diagnosis: The patient has never been diagnosed with any psychiatric disorder or undergone psychotherapeutic interventions.

Substance Current Use and History: The patient denies any history of or current substance abuse or abuse by any member of her family.

Family Psychiatric/Substance Use History: There is no history of any psychiatric condition in her immediate or extended family.

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Psychosocial History: The patient grew up in South Carolina and was raised by both her parents. She has three other siblings, two brothers, and one sister. She is currently a full-time student undertaking a business undergraduate program in Boston. She stays with two other female student roommates in off-campus housing. She is unemployed, has never been married, and not dating. She has no history of legal issues or trouble with the authorities.

Medical History: The patient has never been admitted for any medical treatment.

Current Medications: She is not on any prescription medication for any medical condition.
Allergies:She has no known allergies to drugs or drugs.
Reproductive Hx:Her menarche was at fourteen years. She experiences a regular menstrual cycle. Her last menstrual period was 20 days ago. She is not currently gravid. She has never used any contraceptives and has no children.

ROS:

GENERAL: The patient reports no weight loss but a recent weight gain, no fever, and no generalized weakness.
HEENT: There is no vision loss, hearing loss, dysphagia, sore throat, or nasal congestion.
SKIN: The patient denies pruritus, skin rash, or abnormal skin changes.
CARDIOVASCULAR: There are no reported palpitations, easy fatigability, shortness of breath even on exertion, chest pain, or edema.
RESPIRATORY: There is no difficulty in breathing, no chest pain, and no cough.
GASTROINTESTINAL: The patient denies experiencing anorexia, abdominal pain, nausea, vomiting, diarrhea, or constipation.
GENITOURINARY: Patient reports no pain or discomfort on urination, blood in urine, increased frequency, or incontinence.
NEUROLOGICAL: The patient denies headaches, dizziness, numbness, convulsions, weakness, or paralysis.
MUSCULOSKELETAL: There are no myalgias, no joint swelling, pain, or stiffness.
HEMATOLOGIC: The patient denies anemia or excessive bleeding tendency.
LYMPHATICS: There are no swollen lymph nodes or enlarged spleen.
ENDOCRINOLOGIC: The patient denies intolerance to heat or cold, polyuria, polydipsia, polyphagia, or excessive sweating.

Objective:

Physical exam:

Vital signs: Temperature 98.1, PR-78, RR-18, BP 119/74 Ht 5’2” Wt 184lbs

General: The patient is in fair general condition, is not in any form of distress, is well nourished and is well-kempt.

HEENT: The head is normocephalic, pupils are equally reactive to light, the oral cavity is of good hygiene and free of inflammatory processes, ear canals are clear, and the nose is not congested.

Neck: The neck is soft with no masses, no cervical lymphadenopathy, no thyroid swelling, and no distended neck veins.

Chest/Lungs: The chest moves with respiration, and expands symmetrically, vesicular breath sounds are heard on auscultation with good bilateral air entry.

Heart/Peripheral Vascular: The precordium has normal cardiac activity, the apex beat is not displaced, and first and second heart sounds were heard with no added sounds or murmurs.

Abdomen: The abdomen is not distended, not tender, with no abnormal masses, hepatomegaly, and no splenomegaly. Bowel sounds are present.

Genital/Rectal: Findings from a digital rectal examination were normal.

Musculoskeletal: There is no limitation in the range of movement in all joints. No swelling, stiffness, deformity, or tenderness was noted.

Neurological: Cranial nerve assessment is normal. Motor examination of bulk, tone, power, and reflexes are normal. Sensory examination is intact.

Skin: The skin has no lesions or abnormal changes.

Diagnostic results:

Complete blood count revealed values of cell counts that were within normal ranges.

A toxicology screen of blood and urine samples was negative for any drug.

No organisms were isolated from blood cultures.

Random blood sugar showed serum glucose levels that were within normal ranges.

Thyroid function tests were within normal values.

Blood urea, nitrogen, and creatinine were within normal levels.

Liver function tests were non-contributory.

A head CT scan detected no cranial pathology.

Assessment:

Mental Status Examination: The patient is a 19-year-old female who looks appropriate to her stated age. She is well-groomed and appropriately dressed. She is alert and fully cooperates with the examiner. There is no evidence of motor agitation. Her orientation to place, person, and time is intact. Her speech is clear, coherent, and of normal tone, rate, and volume. She has a depressed mood which is congruent with her affect. She exhibits no evidence of flight of ideas or looseness of association. She experiences occasional suicidal thoughts but has no intention of harming herself or others. She has no auditory or visual hallucinations, or delusions. Her immediate and recent memory is impaired evidenced by not remembering newspaper headlines five seconds after reading them and not recalling what she learns from her classes. Her remote and long-term memory is intact. Her concentration is poor. She lacks insight into her condition. Her judgment is good.

Differential Diagnoses:

1. Bipolar disorder: This is the most likely diagnosis in this patient. This is because the patient exhibits a combination of manic and depressive episodes (Jain et al., 2022). The patient initially experienced a manic episode characterized by elevated mood, increased activity, decreased need for sleep, and increased sociability (Faurholt-Jepsen et al., 2020). During this phase, she could easily make friends and engage in fun activities. The depressive episode that the patient is currently in is characterized by a depressed mood, loss of interest in activities that she initially enjoyed, weight gain, hypersomnia even during classes, reduced concentration, suicidal thoughts, and pessimistic views (Tolentino et al., 2018). The mood disturbance is severe enough to an extent of causing social and functional impairment (Jain et al., 2022). This is evidenced by isolation from her friends whom she initially had cordial relations with. The patient is also having trouble completing her program projects. Bipolar disorder has two incidence peaks of onset the first one being between 15 to 24 years and the second peak occurring between 45 to 54 years (Rowland et al., 2018). The patient is 19 years thus is more predisposed to the first peak. The report by the patient’s mother that the patient gets moody at the same time every year supports the cyclic nature of the condition.

2. Depressive disorder: This is the other probable diagnosis. The symptoms that the patient is currently presenting with are typical of depressive illness. This is supported by the aforementioned symptoms such as depressed mood, reduced energy, suicidal thoughts, and sleep disturbance. The risk factors that predispose to depressive illness that are present in this patient include age, female gender, previous episode based on information from the patient’s mother and stress that probably stems from the program projects (Park et al., 2019). This diagnosis does not, however, explain the experience of manic symptoms.

3. Borderline Personality Disorder: The patient may also be having a borderline personality disorder. This disorder usually presents with pervasive affective instability, impulsiveness, suicidal thoughts, and unstable interpersonal relationships that were evident from the history (Kulacaoglu et al., 2018). This diagnosis does not explain the presence of other depressive symptoms such as hypersomnia and depressed mood.

Reflections: The examiner in this case scenario was remarkable in eliciting important information from the patient that guided the formulation of the diagnosis. Involving the patient’s mother provided corroborative information that filled any gaps in the psychiatric assessment. Privacy and confidentiality of the patient were maintained by conducting the assessment in a room with minimal personnel flow. The patient has never been on any psychiatric treatment thus the formulation of the treatment plan will require the provision of adequate information for an informed choice. There should be no coercion in decision-making regarding the treatment approach. The patient is a teenager thus the involvement of the parents in shared decisions may be necessary. Medication trials that will be considered should be beneficial to the patient with minimal risks. The patient lacks insight thus the need for psychoeducation and education on the need for adherence to treatment recommendations. The patient expresses suicidal thoughts thus as an examiner, I would have further explored the suicide risk such as enquiring about previous attempts or intent.

References

Chapman, J., Jamil, R. T., & Fleisher, C. (2022). Borderline Personality Disorder. In StatPearls. StatPearls Publishing.

Faurholt-Jepsen, M., Christensen, E. M., Frost, M., Bardram, J. E., Vinberg, M., & Kessing, L. V. (2020). Hypomania/Mania by DSM-5 definition based on daily smartphone-based patient-reported assessments. Journal of affective disorders, 264, 272–278. https://doi.org/10.1016/j.jad.2020.01.014

Jain, A., & Mitra, P. (2022). Bipolar Affective Disorder. In StatPearls. StatPearls Publishing.

Kulacaoglu, F., & Kose, S. (2018). Borderline personality disorder (BPD): Amid vulnerability, chaos, and awe. Brain Sciences, 8(11), 201. https://doi.org/10.3390/brainsci8110201

Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568. https://doi.org/10.1056/nejmcp1712493

Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology, 8(9), 251–269. https://doi.org/10.1177/2045125318769235

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: Implications for clinical practice. Frontiers in Psychiatry, 9. https://doi.org/10.3389/fpsyt.2018.00450

NRNP 6635 Assessing and Diagnosing Patients With Mood Disorders