Diagnostic Assessment
Patient: W. M.
Visit: Follow-up Assessment
Source and Reliability: W. M. is a reliable source, mother and grandmother is a reliable source.
Accompanied to appointment by mother.
Referral: Counselor
Subjective:
-does not have the risk factors of suicide at present,
-continues to repeatedly deny having any thoughts nor motivation to harm self nor others,
-does not appear to be in a highly agitated or in an acutely anxious state,
-does not assess to be an imminent risk to self nor others, and
-does not appear to be in an existential crisis.
CC: “ I been feeling like I am not able to control my mood” “I ’m starting to feel weird”
Objective: Pt is short white female; long blonde hair. Talks with head down and when talking appears anxious. Tone is
Vital Signs: 120/77 78 18 98.0 Ht 5’6 Wt 135
Medications: Latuda 20mg po daily. Melatonin 6mg po at HS
HPI: Pt is a 19-year-old that has a history of bipolar came in for a follow-up appointment due to running out of medication due to price and missing an appointment. Pt states she has been off her medication for 30 days. Pt states she noticed that her depression was worse a few days after stopped taking it. Pt states she did not want to get out of bed and go to school or get up to take a bath for a week. Then she noticed that she was making bad decisions according to mother and realized she gets manic when off medication. Pt states she currently has no suicidal ideations but has had some self-reported injuries in her past. Pt also states she was been on Abilify for years then was switched to Latuda and it works very well with her because she gains so much weight with Abilify. The mother reported that during the 30 days she noticed a change in behavior and started to take to the hospital because in the past she has had some inappropriate behaviors that has resulted in sexually transmitted diseases. Mother also reported she has not slept well in the past 2 weeks. Pt denies any other symptoms. Mother is concerned about compliance with medications.
Past Psychiatric History: Pt has a PMH of bipolar Mother reports no history of any psychiatric disorders.
Self-Harm Behavior/Suicide: A. M. denies any suicidal ideation or attempts, Pt has a hx of
cutting 10 years ago. No history of violence or trauma.
Substance Use History: Denies. Nicotine: Denies. Alcohol: Denies. Cannabis: Denies.
Illicit Substances: Denies. Drinks Caffeine daily
Past Medical History: No significant medical history. Immunizations up to date,
Social/Developmental History: Development: At age 19 is in Erickson’s stage of intimacy versus isolation. In this stage, the Pt is trying to develop an intimate relationship with someone. Pt lives with mother and grandmother but has a steady boyfriend that understands her mental health issues. Pt is currently in college and do not live on campus because of a bipolar disorder. Pt admits to fearing commitment which can lead to loneliness and could result to depression.
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Family History: Psychiatric: Mother reports schizophrenia on dad side of the family. Medical: Mother and has DM2 and Dad has HTN, No other major family
medical history. History of self-induced injury. No suicidal attempts
Allergies: None
Medications: Current: Latuda and Melatonin
Psychiatric ROS: Pt states she has not slept for 2 weeks. Pt only slept 3-4 hours a day. No change in appetite. Concentration: Pt is Depression: Reports does not like how she looks and would like to be pretty. Anxiety: Anxiety was Presence and was crying during the assessment.
Physical Exam: Pt denies any issues with physical. No Imaging and or labs. Last physical was a year ago. Pt has a regular PCP and is aware of mental health issues.
Mental Status Exam: The patient is alert and oriented x 4. Dress and hygiene are fair. Calm and cooperative. Good eye contact. No psychomotor agitation or retardation. Speech is normal. No pressure of speech. No thought disorder. Thoughts are goal-directed. Affect is euthymic and appropriate. No emotional blunting. The patient denied any audiovisual hallucinations. No delusions noted. Insight and judgment are fair. Impulse control is fair. The patient is cognitively intact.
General: Neatly dressed and appropriate for the weather, long hair that is down the back.
no make-up; Absence of odor.
Behavior: Alert and Oriented x 4. Denies any hallucinations or delusions. Denies any suicidal or homicidal thoughts. Thought Process: Positive for anxiety, able to sit still during interview, direct eye contact, Speech: Good tone.
Mood: Positive for anxiety. Affect: Appropriate. Thought Process: Clear and
coherent. Thought Content: Denies suicidal or homicidal thoughts, pretty girls at school. General Cognitive State: Coherent, alert. Perceptions: Denies
hallucinations. Sensorium: Alert, oriented x 4. Memory: No memory loss
Insight/Judgment: Made good judgement during the assessment. Intelligence: Intact
Assessment:
Summary: Pt symptoms are not controlled due to not having medications. Mother is concerned about behaviors because she knows the history of her being off her medications. Pt is not sleeping due to being manic.
Diagnosis:
F31.9 Bipolar, unspecified
Symptoms: Have periods of depression and mania. Reports poor sleeping habits and rapid change in mood.
Insomnia
Risk Factor Analysis: The client has a moderate risk for suicide due to being off medication for 30 days and has a history self induced injury. violence toward self due to low
self-esteem; self-view she is not pretty and fat. Protective factors: She is seeking
treatment and wants to have mother’s approval. She is going to school every day, has
agreed to treatment and indicates that she wants to stop self-induced vomiting.
Plan:
Psychiatric/Mental Health Plan:
Continue Latunda 20mg po daily and Melatonin 6mg po at hs for insomnia.
Psychoeducation: Treatment options discussed in detail with patient verbalizing understanding of treatment rationales. Side effects and benefits of all medications prescribed discussed at length between psychiatric prescribing provider and patient along with the risks associated of drug-to-drug interactions, including but not limited to prescription medications, OTC medications, vitamins, minerals and herbal supplements. Patient and provider dialogue showcased verbalized understanding from patient on rationales of medication risk vs benefits.
Information with neurobiology of presenting neurotransmitter disorder, mood stability, sleep hygiene and 7-8 hours of uninterrupted sleep per night with wakeful and refreshed awakening and day long alertness discussed. Reduction of stress and anxiety to aid in focus and concentration discussed, again, with patient physically nodding and engaged in treatment plan with PMHNP-BC perceiving complete understanding of rationale by patient and willingness to adhere to formulated plan of care by prescriber with patient buy-in and willingness to participate actively in plan of care and willing to take charge of own care.
Patient Goals & Plan of Care:
Patients goals for this visit were addressed and met to patient satisfaction as evident by positive communication interactions between prescribing provider and patient.
Prescribing provider further explained plan of care chose treatment options. Patient demonstrated ability to verbally acknowledge understanding of psycho-education and rationale of plan of care as well as treatment option in addition to being able to physically gesture in agreement with appropriate nodding of head and positively perceived facial reactions such as smiling.
Health Promotion: Educate on medications and the Importance of compliance.
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Supplemental Paper: Bipolar Disorder
I selected this paper due to I have not treated a 21-year-old with bipolar. I have always treated ages 25-27 and this patient was diagnosed at 15. I wanted to see her history of medication management to see what was effective and what failed over the years.