Bipolar I Disorder: Diagnosis and Differential Diagnoses
NRNP 6665: PMHNP Care Across the Lifespan I
Subjective:
CC (chief complaint): “Constant anger outburst”
HPI: J.Q is a 27 year old Caucasian female who presented to the office due to her constant outburst toward people, especially her husband. She was previously admitted in Ford County mental health Center in Kansas due to mood. She was also at Shormont Vail hospital in Topeka, Kansas in 2020 for postpartum depression when she almost killed her 2 months old daughter. She was prescribed some psychiatric medication, but she stopped taking it because it was not effective for her. She moved down to Texas with her husband, kids and her parents. She complained of sleep problems, but she takes OTC benadryl and melatonin for sleep. When she was asked to rate her depression on the scale of 1-10, 10 being the worst. She rates her depression 8/10. She persistently sad, feeling empty mood, loss of interest in things she usually love to do. She frequently show anger outburst on her husband, who finally told her that she either et help or lose him and the children, which finally made her seek for help. Sometimes, about 2 to 3 times a week, depression make her feel like people be better off without her, and she cannot figure out the trigger. “ It comes like a light switch”. Mania: She mentioned that one minute, she feels happy and cool, the next minutes, she is fighting with her husband. “Sometimes, I wakes up feeling like a bullet proof, feels like am ontop of the world, and sometimes I don’t feel like doing anything”. She rates her anxiety 0 on the scale of 1-10. Psychosis: She mentioned that before she moved back to Texas, she used to hear voices telling her to take off to a busy road, but not been hearing the voice. She wants to get back to new medication to help her get better
Substance Current Use: She smokes 3-4 ciggarette per day. She denies alcohol or illegal drug use.
Family Psychiatric/Substance Use History: No family history of mental health, unknown death or suicide.
Past psychiatric history: Bipolar, schizophrenia, suicidal thought (Cuts her wrist when she was 13 year old).
Past psychiatric medications: Latuda 80 mg, Saphris (unknown dose), Vrayler( unknown dose), Zoloft (unknown dose), Romeron ( unknown dose).
Medical History: No medical histories
- Current Medications: Benadryl 25 mg at bedtime OTC, melatonin 1 mg at bedtime OTC
- Allergies: Codeine
- Reproductive Hx: Her LMP was 9/13/2022, She is sexually active and currently on a birth control.
Psychosocial History: J.Q was born born and raised in Tyler, Texas. She moved to Kansas and moved back to Texas in march, 2022. She has her high school diploma and current stays at home with her two daughtets. She is married with two children ( 2 year old, and 1 year old). She is currently living with her husband, children, and her parents. She has a good relationship with her parents and siblings. She has two older brothers, and one older sister. She was sexually, emotionally and physically abused by her uncle when she was young. She doesn’t have any legal issues. She had a history of head trauma when her neighbor threw a stone at the back of her head.
ROS:
- GENERAL: Negative for weekness, chills, diaphoresis and fever
- HEENT: Patient had history head trauma, Eyes: Negative for pains, discharge and vitual disturbance. Ear:Negative for congestion, or ear pain. Nose: No nosebleed, sinus, or rhinorrhea. Throat: No sore throat, or throuble swallowing
- SKIN: Negative for rashes
- CARDIOVASCULAR: No chest pain and palpitations.
- RESPIRATORY: Negative for cough, chest tightness or cough.
- GASTROINTESTINAL: Negative for abdominal pain, constipation, diarrhea, and N/V
- GENITOURINARY: Negative for dysuria, flank pain, hematuria, frequency and difficulty urinating.
- NEUROLOGICAL: Negative for dizziness, syncope, weekness, or seizure.
- MUSCULOSKELETAL: Negative for backpain, and myalgias
- HEMATOLOGIC: Negative for anemia or bleeding.
- LYMPHATICS: Negative enlarged node reported.
- ENDOCRINOLOGIC: Negative for cold intolerance, heat intolerance, polyuria and polydipsia.
- PSYCHIATRIC: Reports depression, mood change and anger outburst.
Objective:
Diagnostic results:
Assessment:
Mental Status Examination: The patient is a 27 year old Caucasian female who confirmed that she been feeling mood swing, angerger outburst especially with her husband. She has been getting worse. She was alert and oriented to self, time, location and situation and appeared calm, and cooperative during the interview. She answers allthe questions appropriately. She appears reliable historian. There is no developmental problem. She denies any suicidal thoughts or anxiety at this time, but her problem is depression and frequesnt anger
Diagnostic Impression: You must begin to narrow your differential diagnosis to your diagnostic impression. You must explain how and why (your rationale) you ruled out any of your differential diagnoses. You must explain how and why (your rationale) you concluded to your diagnostic impression. You will use supporting evidence from the literature to support your rationale. Include pertinent positives and pertinent negatives for the specific patient case.
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. Diagnosis/Diagnoses – include all mental health diagnoses and the ICD-10 codes for each. Be Specific with diagnosis
Reflections: . Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrating critical thinking beyond confidentiality and consent for treatment!), social determinates of health, health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
References
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differential diagnoses as well as the treatment plan. Be sure to use correct APA 7th edition formatting.
Subjective:
CC (chief complaint): “Constant anger outburst”
HPI: J.Q is a 27 year old Caucasian female who presented to the office due to her constant outburst toward people, especially her husband. She was previously admitted in Ford County mental health Center in Kansas due to mood. She was also at Shormont Vail hospital in Topeka, Kansas in 2020 for postpartum depression when she almost killed her 2 months old daughter. She was prescribed some psychiatric medication, but she stopped taking it because it was not effective for her. She moved down to Texas with her husband, kids and her parents. She complained of sleep problems, but she takes OTC benadryl and melatonin for sleep.
When she was asked to rate her depression on the scale of 1-10, 10 being the worst. She rates her depression 8/10. She persistently sad, feeling empty mood, loss of interest in things she usually love to do. She frequently show anger outburst on her husband, who finally told her that she either et help or lose him and the children, which finally made her seek for help. Sometimes, about 2 to 3 times a week, depression make her feel like people be better off without her, and she cannot figure out the trigger.
“ It comes like a light switch”. Mania: She mentioned that one minute, she feels happy and cool, the next minutes, she is fighting with her husband. “Sometimes, I wakes up feeling like a bullet proof, feels like am ontop of the world, and sometimes I don’t feel like doing anything”. She rates her anxiety 0 on the scale of 1-10. Psychosis: She mentioned that before she moved back to Texas, she used to hear voices telling her to take off to a busy road, but not been hearing the voice. She wants to get back to new medication to help her get better
Substance Current Use: She smokes 3-4 ciggarette per day. She denies alcohol or illegal drug use.
Family Psychiatric/Substance Use History: No family history of mental health, unknown death or suicide.
Past psychiatric history: Bipolar, schizophrenia, suicidal thought (Cuts her wrist when she was 13 year old).
Past psychiatric medications: Latuda 80 mg, Saphris (unknown dose), Vrayler( unknown dose), Zoloft (unknown dose), Romeron ( unknown dose).
Medical History: No medical histories
- Current Medications: Benadryl 25 mg at bedtime OTC, melatonin 1 mg at bedtime OTC
- Allergies: Codeine
- Reproductive Hx: Her LMP was 9/13/2022, She is sexually active and currently on a birth control.
Psychosocial History: J.Q was born born and raised in Tyler, Texas. She moved to Kansas and moved back to Texas in march, 2022. She has her high school diploma and current stays at home with her two daughtets. She is married with two children ( 2 year old, and 1 year old). She is currently living with her husband, children, and her parents.
She has a good relationship with her parents and siblings. She has two older brothers, and one older sister. She was sexually, emotionally and physically abused by her uncle when she was young. She doesn’t have any legal issues. She had a history of head trauma when her neighbor threw a stone at the back of her head.
ROS:
- GENERAL: Negative for weekness, chills, diaphoresis and fever
- HEENT: Patient had history head trauma, Eyes: Negative for pains, discharge and vitual disturbance. Ear:Negative for congestion, or ear pain. Nose: No nosebleed, sinus, or rhinorrhea. Throat: No sore throat, or throuble swallowing
- SKIN: Negative for rashes
- CARDIOVASCULAR: No chest pain and palpitations.
- RESPIRATORY: Negative for cough, chest tightness or cough.
- GASTROINTESTINAL: Negative for abdominal pain, constipation, diarrhea, and N/V
- GENITOURINARY: Negative for dysuria, flank pain, hematuria, frequency and difficulty urinating.
- NEUROLOGICAL: Negative for dizziness, syncope, weekness, or seizure.
- MUSCULOSKELETAL: Negative for backpain, and myalgias
- HEMATOLOGIC: Negative for anemia or bleeding.
- LYMPHATICS: Negative enlarged node reported.
- ENDOCRINOLOGIC: Negative for cold intolerance, heat intolerance, polyuria and polydipsia.
- PSYCHIATRIC: Reports depression, mood change and anger outburst.
Objective:-
Diagnostic results:
Assessment:
Mental Status Examination: The patient is a 27 year old Caucasian female who confirmed that she been feeling mood swing, angerger outburst especially with her husband. She has been getting worse. She was alert and oriented to self, time, location and situation and appeared calm, and cooperative during the interview. She answers all the questions appropriately. She appears reliable historian. There is no developmental problem. She denies any suicidal thoughts or anxiety at this time, but her problem is depression and frequesnt anger
Diagnostic Impression:
Differential diagnoses
- Bipolar I disorder (primary diagnosis)
o ICD-10 code: F31.1- Bipolar disorder, current episode manic without psychotic features
- Major depressive disorder
- ICD-10 code: F33.1-Major depressive disorder, recurrent, moderate
- Cyclothymic disorder
- ICD-10 code: F34.0-Cyclothymic disorder
Rationale
Bipolar I Disorder
Bipolar I disorder fits best as the patient’s primary diagnosis because her symptoms match those of bipolar I disorder more closely when compared with major depressive and cyclothymic disorders. The patient’s symptoms adequately align with the DSM-5 diagnostic criteria for bipolar I disorder. For instance, the patient presents with a combination of manic episodes lasting at least 7 days and major depressive disorder lasting at least 2 weeks which confirms the presence of bipolar I disorder (Grunze et al., 2021).
Manic episodes are evidenced by abnormally elevated feelings characterized by increased energy. Episodes of major depressive disorder are evidenced by depressed mood, loss of interest in activities, sadness, a sense of worthlessness, and sleep disturbance. Besides, the manic and major depressive episodes cannot better be attributed to other factors such as schizoaffective disorder, other psychotic disorders, schizophrenia spectrum disorder, or delusional disorder (Grunze et al., 2021).
The healthcare provider should conduct a mental health examination using the listed DSM-5 criteria to confirm or rule out the presence of bipolar I disorder. The National Institute of Mental Health recommends an evaluation of the patient’s symptoms, medical history, family history, and life experiences during a mental assessment.
Major Depressive Disorder
Major depressive disorder is another differential diagnosis that can be considered in the patient’s case. The reason is that some of the symptoms displayed by the patient match the DSM-5 diagnostic criteria for major depressive disorder. For example, the patient presents with a depressed mood, loss of interest in activities, sadness, a sense of worthlessness, and sleep disturbance.
However, the major depressive disorder has not been considered as the primary diagnosis because the patient also presents with manic episodes which should not occur in a person with major depressive disorder (Tolentino & Schmidt, 2018). Mental health diagnosis for the patient should entail psychiatric evaluation using the DSM-5 criteria for major depressive disorder as a comparison. The mental health professional can use a questionnaire to collect relevant information from the patient that reflects her behaviors and feelings.
Cyclothymic Disorder
Another possible diagnosis for the patient is cyclothymic disorder. Some of the patient’s symptoms match the DSM-5 diagnostic criteria for cyclothymic disorder. As outlined in the DSM-5 diagnostic criteria, persons with a cyclothymic disorder should have numerous episodes of depression and hypomania symptoms for a period of at least two years (Mayo Clinic, 2021). These symptoms should not be adequate to confirm the presence of a major depressive disorder or bipolar disorder.
Additionally, the symptoms cannot be attributed to a mental disorder, substance abuse, or a medical condition. Furthermore, the symptoms should cause an impairment in a person’s functional abilities (Mayo Clinic, 2021). The cyclothymic disorder has not been considered as the patient’s primary diagnosis because her depressive and manic symptoms are adequate to confirm the presence of bipolar I disorder. The mental health diagnosis for the patient should entail mood charting and psychological assessment to find symptoms that match the DSM-5 criteria.
Reflections:
The most appropriate diagnosis for the patient is bipolar I disorder. I agree with my preceptor’s assessment and diagnostic impression of the patient. The reason is that the named diagnosis is aligned with the DSM-5 diagnostic criteria for bipolar I disorder (Grunze et al., 2021).
An important lesson learned from the case is that mental health professionals should understand specific symptoms associated with different mental illnesses and be able to establish when a person has multiple psychological issues at a time. When handling a patient with similar symptoms next time, I will work closely with family members in order to understand his or her past experiences.
Legal/ethical considerations: Adhering to the ethical code of conduct and legal provisions for mental health practice will increase healthcare quality and promote healing (Risling et al., 2021).
Social determinants of health and health promotion: Teaching the patient about the diagnosis and supporting her to obtain insurance will promote well-being. Again, the patient should eat a healthy diet and engage in exercise as part of her health promotion activities (Risling et al., 2021).
References
Grunze, A., Born, C., Fredskild, M. U., & Grunze, H. (2021). How does adding the DSM-5 criterion increased energy/activity for mania change the bipolar landscape?. Frontiers in Psychiatry, 12, 638440. https://doi.org/10.3389/fpsyt.2021.638440
Mayo Clinic. (2021). Cyclothymia: Cyclothymic disorder. https://www.mayoclinic.org/diseases-conditions/cyclothymia/diagnosis-treatment/drc-20371281
National Institute of Mental Health. (2020). Bipolar disorder. https://www.nimh.nih.gov/health/topics/bipolar-disorder
Risling, T., Carlberg, C., Kassam, I., Moss, T., Janssen, P., Iduye, S., & Strudwick, G. (2021). Supporting population mental health and wellness during the COVID-19 pandemic in Canada: protocol for a sequential mixed-method study. BMJ Open, 11(11), e052259. https://doi.org/10.1136/bmjopen-2021-052259
Tolentino, J. C. & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: Implications for clinical practice. Frontiers in Psychiatry, 9, 45 https://doi.org/10.3389/fpsyt.2018.00450