Bipolar II Disorder Evaluation

Subjective: CC: ” I have a history of taking medications and then stopping them. I don’t think I need them. I really feel like the medication squashes who I am.” HPI: Patient PP is a 25-year-old female patient who has come for a mental health assessment. The patient reports having problems with medication adherence, indicating her lack of need for the medication, stating that it “squashes” who she is. The patient also reports having been hospitalized as a teenager for going four to five days without sleep and hearing things during the period. Since then, she has been hospitalized four times, with the current hospitalization being the past spring. She notes that she has previously been diagnosed with bipolar, anxiety, and depression. She also notes that she tried to use some medications like Zoloft, Seroquel, and another one which she only recalls the name to start with the letter “L”. The patient explains that her prescribed medications seem to present some side effects. The patient also notes that she has once had some suicidal tendencies before. She also reports engaging in sexual intercourse with multiple partners since it elevates her moods. She also reports missing work due to feeling too depressed. Substance Current Use and History: The patient reports smoking at least a packet of cigarettes a day, which she doesn’t intend to stop. She also reports having stopped using alcohol at 19 years. The patient also reports having a bad history of marijuana use which made her stop. She denies using cocaine, stimulant, inhalants, hallucinogens, and sedative medications. She also denies using any pain pills or opiate medications. Family Psychiatric/Substance Use History: The patient reports having a family background with psychiatric and substance use issues. She indicates that her mother was bipolar with suicidal tendencies. She reports that her father was imprisoned for 8 to 10 years due to drug-related problems, and she considers her brother to also have mental issues though not hospitalized. Psychosocial History: The patient was raised by her mother and her older brother. She currently lives with her boyfriend and at times her mother who is infuriated by her sexual habits. Her father is imprisoned and has not heard from him for some time. She has never been married before or had any children. She is currently working in her aunt’s stores albeit irregularly due to her occasional depressed moods. She is currently studying cosmetology and loves to paint and write. Medical History: The patient has Polycystic ovary syndrome (PCOS) and hypothyroidism.
  • Current Medications: the patient is currently under birth control pills for PCOS and an unnamed medication for hypothyroidism. She is also currently using some medication for her mental illness which she only remembers the first letter being “L.” She notes to have previously used Zoloft and Seroquel.
  • Allergies:No allergies reported by the patient
  • Reproductive Hx:The patient reports having her regular menses once a month, with the last one being sometime last month. She is diagnosed and under medication for PCOS. She reports being sexually active and with multiple partners
ROS:
  • GENERAL: Varying levels of eating and sleeping depending on the mood.
  • HEENT: negative for head traumas, hearing, sight, smell, neck, or throat problems.
  • SKIN: Negative for dryness, itching, or rashes.
  • CARDIOVASCULAR: Negative for CV issues.
  • RESPIRATORY: Negative for respiratory symptoms.
  • GASTROINTESTINAL: Negative for GI pain, diarrhea, nausea, or vomiting.
  • GENITOURINARY: Reports negative for GU symptoms.
  • NEUROLOGICAL: Reports negative for neurological issues.
  • MUSCULOSKELETAL: denies having any MS problems.
  • HEMATOLOGIC: denies having any abnormal bleeding or hematologic issues.
  • LYMPHATICS: Denies lymphadenopathy.
  • ENDOCRINOLOGIC: Reports having hypothyroidism
Objective: Physical Exam
  • Vital signs: RR: 18, PR: 90, T: 98.2, B/P: 138/88
  • HEENT: Noncontributory
  • Res: No wheezing or distress in breathing
  • CV: Regular HR, BP, no murmurs or bruits
Diagnostic results: Laboratory Data Available: The available laboratory results indicate negative for Urine drug and alcohol screen. The CBC, CMP, and lipid panel are within the optimal range. TSH levels indicative of subclinical hypothyroidism. Assessment: Mental Status Examination:  The patient appears well dressed for the occasion. She is alert and well oriented to time, place, person, and occasion. She maintains eye contact throughout the session. She also appears to be hyper and chuckles throughout the interview. She answers the questions eloquently and has a good memory of several life events. but finds some questions about family and suicide irritating or personal. She denies having any delusions, nightmares, or paranoia. She confirms to have a history of suicidal ideation. Diagnostic Impression: 
  • Bipolar II Disorder DSM-5 296.89 (F31.81)- primary diagnosis
  • Generalized Anxiety Disorder (GAD) DSM-5 300.02 (F41. 1)
  • MDD, Severe recurrent unspecified DSM-5 296.23 (33.9)
From the presented information and assessment of the patient’s condition, the selected primary diagnosis is bipolar II disorder. Bipolar II disorder is a mood disorder characterized by hypomania and depression. The condition causes unusual mood changes, energy level, concentration, and ability to perform routine activities, which if left untreated can cause severe harm or even death to the patient or those around the patient among other serious consequences (CrashCourse. 2018). The selection of bipolar II disorder as the primary diagnosis was based on the DSM guidelines which indicate the presence of at least five symptoms. From the information obtained, the symptoms that seem to align with the primary diagnosis include having depression and hypomanic episodes, significant changes in eating and sleeping patterns as a result of mood changes, occasional loss of interest in daily activities, including those that are considered fun to do, and compulsive behavior. Reflections: The presented case provides insight into a patient with possible bipolar disorder. The patient presents various aspects that put her at risk of getting a mood disorder. Some of these risk factors include a family history of mental illness, and a diagnosis of PCOS, whereby, evidence shows that patients with PCOS have an increased likelihood of getting the condition (Qadri et al., 2018). One of the aspects that should be considered when creating a suitable treatment plan is the fact that the patient has hypothyroidism. According to a study by Li et al. (2019), hypothyroidism was noted to be the commonest abnormality among patients with bipolar disorder. Some of the treatment options for hypothyroidism like lithium could have some reactions when dealing with patients with bipolar disorder and should therefore be considered when implementing the treatment plan. One of the ethical considerations for this case is beneficence and non-maleficence, whereby, the patient’s wellbeing will be given priority when selecting the most appropriate treatment plan. This includes selecting medication in consideration of the potential interactions and adverse effects that could affect the patient and her history of nonadherence. Plan Since the patient is using lithium for hypothyroidism, she could also use the same for bipolar but with dosage adjustments to prevent adverse reactions reported earlier. This selection is based on the study by Volkmann et al. (2020), which supports the medication as a first-line treatment option for bipolar disorder. Follow-up should be done after a month to confirm the patient’s adherence to the treatment therapy and tolerability of the drug. Patient education on responsible and safe sexual behavior is important to reduce the risk of getting sexually transmitted infections or unwanted pregnancy, among other issues. References CrashCourse. (2014, September 8). Depressive and bipolar disorders: Crash course psychology #30 [Video]. YouTube. https://www.youtube.com/watch?v=ZwMlHkWKDwM&t=1s Li, C., Lai, J., Huang, T., Han, Y., Du, Y., Xu, Y., & Hu, S. (2019). Thyroid functions in patients with bipolar disorder and the impact of quetiapine monotherapy: a retrospective, naturalistic study. Neuropsychiatric Disease and Treatment, 15, 2285. https://doi.org/10.2147/NDT.S196661 Qadri, S., Hussain, A., Bhat, M. H., & Baba, A. A. (2018). Polycystic Ovary Syndrome in Bipolar Affective Disorder: A Hospital-based Study. Indian journal of psychological medicine, 40(2), 121–128. https://doi.org/10.4103/IJPSYM.IJPSYM_284_17   Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium treatment over the lifespan in bipolar disorders. Frontiers in Psychiatry, 11, 377. https://doi.org/10.3389/fpsyt.2020.00377