Comprehensive Psychiatric Evaluation of a Patient with a Mood Disorder: Bipolar I Disorder in a 27 Year-Old African American Male

‘Bipolar and Related Disorders’ is a diagnostic category of mental health conditions in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The diagnostic group of disorders is considered as a bridge between ‘Schizophrenia and other Psychotic Disorders’ on the one hand, and ‘Depressive Disorders’ on the other. The reason as to why the diagnostic group is placed between these two in the DSM-5 is that its symptoms are a transition from one to another (Sadock et al., 2015; APA, 2013). Management of bipolar disorder by the psychiatric-mental health nurse practitioner or PMHNP involves assessment, pharmacotherapy, psychotherapy, and close follow up post initiation of treatment (ANA, 2014). Patient BM is a 27 year-old African American male who presents to the clinic with hyperactivity, elation, inappropriate dressing, rapid speech and tangential thoughts, and talkativeness. Tests conducted earlier by the referring primary physician showed no physical disease or medical condition and indicated that his physical health was sound. The Young Mania Rating Scale (YMRS) was used to assess the degree of his mania since it was clear that he was presenting in the manic phase of the bipolar disorder (Mohammadi et al., 2018). The purpose of this paper is to conduct a comprehensive psychiatric evaluation on the 27 year-old African American male presenting with symptoms of bipolar I disorder. The comprehensive psychiatric assessment takes the form of a SOAP note accompanied by a mental status examination (MSE), differential diagnoses, and a reflection.  Comprehensive Psychiatric Evaluation Essay Paper

Subjective

CC (chief complaint): The patient is brought to the clinic by his fiancée with a complaint of hyperactivity, increased energy, insomnia, distractibility, mood disturbance causing impairment in functioning, and reckless behavior previously uncharacteristic of him.

HPI: The patient is a 27 year-old African American male presenting with excessive hyperactivity and ease of distractibility. The presenting symptoms include euphoria, exaggerated self-importance, talkativeness, racing thoughts, and agitation. The historian (his fiancée) denies a previous history of the same symptoms that he is presenting with. The onset of the above symptoms was about two weeks ago when the fiancée started noticing strange behavior from him. The location of his symptoms is in his psyche, in his mind. The symptoms are constant and unrelenting and are characterized by pervasiveness. They are aggravated by the patient being outdoors and when he takes alcohol. Relief of the symptoms comes only when he finally manages to get some sleep. The timing of the symptoms is all day with no particular time of the day. On a scale of 0-10, the fiancée who was the historian gives him a score of 6/10.

Past Psychiatric History: The patient does not have any past history of psychiatric conditions himself. However, he does have a history of moving from job to job because of behavior that is congruent with the symptoms that he is presenting with now.

• General Statement: This patient is a 27 year-old mechanic who stays with his fiancée and who has been well until two weeks ago. The current symptoms he presents with are causing him social, occupational, and self-care dysfunction. He is currently without a job and depends on his fiancée for upkeep.
• Caregivers (if applicable): Because of the reckless behavior and the distractibility, this patient requires having somebody looking over him so that he does not harm himself. At the moment, the person carrying out this caregiver duty is his fiancée. Because of the insomnia, sometimes he does not even know when to stop.
• Hospitalizations: The patient has never been admitted with a psychiatric diagnosis before. The only admission was for pneumonia in 2015.
• Medication trials: This patient has never participated in any medication trials, whether for psychiatric pharmacotherapeutic agents or otherwise.
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has never been officially diagnosed with any psychiatric illness. Because of that, he has never received any psychotherapeutic treatment for such conditions.

Substance Current Use and History: This patient has been a smoker since he was 18 years old. He now smokes an average of 12 sticks per day. He is also a partaker of etoh and has been drinking from the age of 19 years old. He usually drinks over the weekends with friends, but occasionally gets involved in binge drinking. This has placed him n many occasions in awkward situations. He denies using cannabis sativa or any other substance, including the hard drugs like cocaine.

Family Psychiatric/Substance Use History: In his family, his mother suffered from depression and has been managed successfully with her being in remission now. There is also a paternal uncle who committed suicide in 2017 after being diagnosed with bipolar disease. All his siblings are in good health. His father is a social drinker but also smokes a pack of cigarettes every day. There is no other history of substance use within his family.

Psychosocial History: The patient is an outgoing person and an extrovert by nature. He lives with his fiancée but does not yet have any children of his own. His fiancée also does not have any children. He has close circle of friends with whom he frequently goes out together with his fiancée. The weekends are usually reserved for relaxation and merry making. During these occasions, they usually drink and eat out. His social support network is good as his two other older siblings also visit regularly to check on him. The parents are also still alive and live within the same state. When he gets the time, he occasionally visits his parents. He lives with his girlfriend in a densely populated residential area that lacks some amenities. The public transport is good though. He does not have a personal car and uses the public transport system to and from work. Some of his hobbies include watching movies, playing pool, and listening to music.

Medical History: He was admitted in the year 2015 with a diagnosis of community-acquired pneumonia and spent a week in the hospital. He does not have any other history of admission or affliction with any other significant illness. He completed his immunizations as a child and has received several other vaccines as an adult. In 2017 he received Tdap booster, in 2019, he got the influenza vaccine, and this year he has received both doses of the Astra Zeneca Covid-19 vaccine.

ORDER A PLAGIARISM-FREE PAPER HERE

• Current Medications: He is currently not on any medications; be they conventional, alternative therapies, or home therapies.
• Allergies: He denies having any allergies to food and food products, medications, or environmental allergens.

• Reproductive Hx: The 27 year-old patient is heterosexual and has a girlfriend. However, he does not have any children as yet.  

ROS: Negative in all systems.

Objective

Physical exam: The patient is alert and oriented in place, person, time, and event. He is appropriately dressed for the weather and the time of the day.

Diagnostic results:

• Young Mania Rating Scale (YMRS) score of 21 (mild mania)
• WBC 7,100
• Negative drug tests for cocaine and cannabis sativa.

Vitals: P 72; BP 120/70 mmHg normal cuff and sitting; RR 16; T 99.0°F; BMI 23.9 kg/m².  Comprehensive Psychiatric Evaluation Essay Paper

Assessment

Mental Status Examination (MSE)

The patient is a 27 year-old African American male who is a mechanic and lives with his fiancée. His grooming is appropriate for the time of the day and the weather. His speech is spontaneous, coherent, clear, and goal-directed most of the times. However, he displays clear verbosity and tangential thinking. There are no obvious mannerisms, gestures, or tics. His self-reported mod is “elated” while his observed affect is euphoric. There is absolute congruency between the mood and the affect. He has no suicidal or homicidal ideation and does not show any hallucination s or delusions. His thoughts are racing and he veers off easily from the topic at hand. His insight and judgement are somewhat impaired. Diagnosis: Bipolar I Disorder (Sadock et al., 2015; APA, 2013; Stahl, 2013).

Differential Diagnoses

1. Bipolar I disorder

This is the most likely primary diagnosis given the fact that the symptoms with which the patient has presented with align very well with the diagnostic criteria (for bipolar I disorder) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5 (Sadock et al., 2015; APA, 2013). According to the American Psychological Association (APA, 2013), the diagnosis of bipolar I disorder is made when there is at least one manic episode in the lifetime of a patient. The symptoms that this patient has presented with include distractibility, racing thoughts (tangential thinking), disturbance in sleep patterns, euphoria, exaggerated self-importance, talkativeness, agitation and hyperactivity. These are clear symptoms of bipolar I disorder and this is why the condition has been chosen as the primary diagnosis. They demonstrate that he is in the manic phase of bipolar I disorder.

Some of the DSM-5 diagnostic criteria that must be met for the diagnosis of bipolar I disorder to be made as in the case of this patient include (for the manic episode) abnormally increased intensity in goal-directed activity, grandiose delusions, psychomotor agitation, reckless behavior, flight of ideas, significant impairment in social and occupational functioning, and inability to attribute the symptoms to the physiological effects of a substance/ drug or another medical condition (Sadock et al., 2015; APA, 2013).

2. Major Depressive Disorder (MDD)

According to the American Psychological Association (APA, 2013) and Sadock et al. (2015), the condition that is MDD can also be accompanied by periods of mania and hypomania. The complexity in diagnosis also increases since the patient with MDD may also display irritability just like the one with bipolar I disorder. In the case where the patient with MDD presents in major depression episode, proper history must therefore be taken to rule out previous episodes of mania. This is the only way to distinguish MDD from bipolar I disorder.

The DSM-5 diagnostic criteria for the diagnosis of MDD includes having a feeling of worthlessness, having a depressed mood most of the time for most days, self blame, disturbance in sleep patterns, avoidance of interpersonal interactions, thoughts about death and dying, and impairment in social/ occupational/ self care functions (APA, 2013). This differential diagnosis has however not been chosen as the primary diagnosis because it does not include some of the symptoms the patient presented with such as racing thoughts (tangential thinking), disturbance in sleep patterns, euphoria, exaggerated self-importance, talkativeness, and agitation.

3. Attention-Deficit/ Hyperactivity Disorder (ADHD)

Attention-deficit/ hyperactivity disorder or ADHD is a neurodevelopmental condition that usually manifests first in childhood as problems with learning. The main symptoms are hyperactivity, inattention, or both. The patent usually cannot sustain attention on one thing for long and gets quickly distracted by other things. They are also more often than not hyperactive with intense psychomotor agitation. Just by these descriptions, it can be seen how this presentation is similar to that of bipolar I disorder.

ADHD symptoms often continue into adulthood and cause significant dysfunction in the patient’s everyday life. Some of the DSM-5 diagnostic criteria that make the differential diagnosis of ADHD a consideration after bipolar I disorder include self-isolation from peers, distractibility, inattention, psychomotor agitation, and learning difficulties (APA, 2013). This differential diagnosis has however not been chosen as the primary diagnosis because it does not include some of the symptoms the patient presented with such as racing thoughts (tangential thinking), disturbance in sleep patterns, euphoria, exaggerated self-importance, talkativeness, and agitation.  Comprehensive Psychiatric Evaluation Essay Paper

Plan

The plan for psychotherapy will be to start the patient on cognitive behavioral therapy (CBT) so that he may undergo cognitive remodelling to change his thoughts (Corey, 2017). As for the psychopharmacological plan, he would be commenced on lithium (Eskalith) 300 mg by mouth twice every day (Stahl, 2017). These two therapies will run concurrently for best results. Health education will involve educating the patient to try and stop drinking and smoking as these behaviors encourage a reckless attitude that only worsens the symptoms. Also, it will be important to let the patient know that as far as the lithium is concerned, they should:

• Take only the prescribed amount of the drug; no more, no less.
• Swallow the tablet whole without chewing or crushing it.
• Report promptly to the healthcare worker any side effects noted such as drowsiness, tremors of the hand, headache, and thirst amongst others (Katzung, 2018).

Reflections: If I were to be given the opportunity to do this evaluation again, I would not change the way I have done things. I have followed the evidence-based protocols for examination and history taking. This means that the patient has received evidence-based care as required in best practice. A lot of critical thinking has gone into the diagnostic tests as well as the differential diagnoses. To arrive at the primary diagnosis, I have had to closely compare the symptoms the patient presented with and the diagnostic criteria for bipolar I disorder in the DSM-5. Furthermore, I have accorded the patient autonomy by involving them in the decision for therapy and treatment plan (Haswell, 2019). The decision to adopt a two-pronged approach to treatment is also informed by the bioethical principle of beneficence. This is because I am aware of evidence from available scholarly literature that states that a combination of CBT and lithium (psychotherapy combined with pharmacotherapy) is the best treatment for bipolar I disorder (Chiang et al., 2017; Rybakowski, 2014).

Conclusion

Bipolar I disorder is a condition recognized by the DSM-5 and which has specific diagnostic criteria within it. A patient with the condition will display characteristic symptoms but which at times may also resemble other conditions such as MDD and ADHD. Just like in the above case, the evaluation of the patient presenting with suspected bipolar I disorder must be thorough to avoid misdiagnosing the other conditions appearing as differential diagnoses.

• Select a patient (an adult) that you examined during the last 7 weeks.
• Create a Focused SOAP Note on this patient using the template provided in the Learning Resources.

• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
• Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.
• Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.  Comprehensive Psychiatric Evaluation Essay Paper