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A comprehensive case study of sarah jamieson, a patient presenting with mood instability, depressive episodes, and impulsive behaviors. It details her medical history, physical exam findings, and psychiatric assessment, leading to a diagnosis of bipolar i disorder. The diagnostic process, differential diagnoses, and a detailed treatment plan, including medication management, psychotherapy, and lifestyle modifications. It also includes laboratory tests and psychiatric assessments conducted to support the diagnosis.
Typology: Exams
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Patient History: Sarah Jamieson
o Currently on mood stabilizers, antidepressants, or other psychiatric medications? o History of medication noncompliance?
Physical Exam for Sarah Jamieson
A physical exam in the context of a psychiatric evaluation is primarily used to rule out medical conditions that might contribute to mood instability. Below is a structured physical exam based on Sarah Jamieson's case:
General Appearance:
Well-groomed or disheveled? Signs of psychomotor agitation (restlessness, excessive movement) or retardation (slow movements, low energy)? Eye contact: appropriate, poor, or intense?
Vital Signs:
Blood Pressure (BP): Elevated or within normal range? (Hypertension could indicate anxiety or stimulant use.) Heart Rate (HR): Elevated in mania, anxiety, or stimulant use. Respiratory Rate (RR): Normal vs. increased (could indicate anxiety or substance withdrawal). Temperature: Rule out fever (infection-related causes of delirium). Weight/BMI: Any significant weight loss/gain (suggestive of depression, metabolic issues, or medication side effects)?
Neurological Exam:
Summary & Clinical Considerations:
Key psychiatric signs: Pressured speech, impulsivity, mood lability, risky behaviors. Rule out medical conditions like thyroid dysfunction, substance withdrawal, or neurological issues. Next steps: Further psychiatric assessment, lab tests (thyroid function, liver enzymes for alcohol use, drug screening if needed).
Assessment: Sarah Jamieson
Primary Diagnosis: Bipolar Disorder (Likely Type I or II)
Based on Sarah Jamieson’s history, symptoms, and physical exam findings, the most likely diagnosis is Bipolar Disorder due to the presence of:
Manic/hypomanic episodes (elevated mood, impulsivity, risky behaviors, decreased need for sleep). Depressive episodes (low mood, depression, possible substance use as self-medication). Mood cycling over time. Risky behaviors, including alcohol use.
Differential Diagnoses:
o Impulsivity and mood swings may suggest ADHD. o A history of childhood symptoms and executive dysfunction is needed.
Risk Assessment:
Suicidal Ideation: Any history of self-harm or suicide attempts? Homicidal Ideation: Any aggressive behavior towards others? Substance Use: Alcohol use may exacerbate mood instability.
Plan & Next Steps:
Complete Blood Count (CBC)
✅ Results: Possibly low (linked to depression). ✅ Why?
Deficiencies can contribute to fatigue, mood swings, and cognitive changes.
Mood Disorder Questionnaire (MDQ)
✅ Results: Positive for Bipolar Disorder (meets threshold for manic/hypomanic symptoms). ✅ Why?
Screens for bipolar symptoms and severity.
Montreal Cognitive Assessment (MoCA) / Mini-Mental State Exam (MMSE)
✅ Results: Normal cognitive function. ✅ Why?
Rules out cognitive impairment (e.g., alcohol-related brain changes).
Brain MRI / CT Scan
✅ Results: Normal (unless structural abnormalities). ✅ Why?
Used only if there are neurological symptoms (seizures, memory loss, head trauma history) to rule out organic brain disease.
Summary of Test Findings:
Likely Findings: o Liver function abnormalities (AST/ALT elevated due to alcohol use). o Positive Mood Disorder Questionnaire (MDQ) – Suggestive of Bipolar Disorder. o Possible Vitamin D or B12 Deficiency. o Negative Urine Drug Screen (except alcohol, if recently consumed). o Thyroid function normal (unless underlying issue).
Diagnosis: Sarah Jamieson
Primary Diagnosis:
✅ Bipolar I Disorder (Most Likely) – F31.81 (ICD-10 Code) ✅ Rationale:
History of mood cycling between manic/hypomanic episodes (elevated mood, impulsivity, risky behaviors) and depressive episodes (low mood, alcohol use, withdrawal). Symptoms of mania/hypomania (impulsivity, decreased need for sleep, risky behaviors). No evidence of alternative medical conditions causing mood swings.
Differential Diagnoses:
✅⃣ Substance-Induced Mood Disorder (Alcohol-Related) – F10.
Mood instability could be worsened by alcohol use. Requires further assessment of alcohol’s role in symptoms.
✅⃣ Major Depressive Disorder (MDD) with Impulsivity – F33.
Valproate (Depakote) (alternative if lithium is contraindicated). Lamotrigine (Lamictal) (better for bipolar depression).
✅ Atypical Antipsychotics:
Quetiapine (Seroquel), Aripiprazole (Abilify) (for acute mania and maintenance).
✅ Avoid Antidepressants Alone – Can trigger manic episodes.
If depression is severe, SSRIs may be added cautiously with a mood stabilizer.
✅ Cognitive Behavioral Therapy (CBT): Helps with mood regulation and coping strategies. ✅ Dialectical Behavioral Therapy (DBT): Useful if impulsivity and risky behaviors are prominent. ✅ Psychoeducation: Teach Sarah about bipolar disorder, medication adherence, and mood tracking.
✅ Alcohol Use Counseling: Assess for Alcohol Use Disorder (AUD) and provide support. ✅ Motivational Interviewing: Encourage reducing alcohol intake to stabilize mood. ✅ Support Groups: Recommend Alcoholics Anonymous (AA) or SMART Recovery.
✅ Sleep Hygiene: Establish consistent sleep schedule (important for bipolar stability). ✅ Exercise & Diet: Regular physical activity and a balanced diet to support mental health. ✅ Stress Management: Meditation, mindfulness, journaling, or relaxation techniques.
✅ Follow-up in 1-2 weeks to assess medication response and mood stability. ✅ Regular psychiatric appointments for long-term mood stabilization. ✅ Lab Monitoring (if on lithium or valproate):
Lithium levels (every 4-6 weeks initially). Liver function tests & CBC (if on valproate). Kidney function tests (for lithium).
Summary of Plan:
✅⃣ Start mood stabilizer (Lithium or Valproate) & monitor response. ✅⃣ Psychotherapy (CBT/DBT) for mood and impulse control. ✅⃣ Reduce alcohol use with counseling and support groups. ✅⃣ Encourage lifestyle changes (sleep, exercise, stress management). ✅⃣ Regular follow-ups & lab monitoring for medication safety.