Bipolar Disorder Case Study: Sarah Jamieson, Exams of Nursing

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NR602 I HUMAN CASE WEEK 6

SARAH JAMIESON WHO PRESENTS

FOR MOOD ASSIGNMENT

CHAMBERLAIN UNIVERSITY 2025

Patient History: Sarah Jamieson

1. Chief Complaint (CC): o Presents with mood instability, depressive episodes, and impulsive behaviors.
2. History of Present Illness (HPI): o Reports ongoing mood swings for several years. o Episodes of elevated mood with increased energy, reduced need for sleep, and impulsive decisions. o Alternating periods of depression, low energy, and feelings of hopelessness. o Engages in risky behaviors, including alcohol use.
3. Past Psychiatric History: o Possible previous diagnosis of bipolar disorder or related mood disorder. o History of depressive and manic/hypomanic episodes. o Possible prior psychiatric hospitalizations or therapy.
4. Medical History: o No major physical health concerns reported (unless specified). o Any history of substance use affecting mental health?
5. Family History: o Family history of mood disorders, such as bipolar disorder or depression? o Any genetic predisposition to mental health conditions?
6. Social History: o Possible stressors, including work, relationships, or financial issues. o History of substance use (alcohol). o Support system – family, friends, or therapy?
7. Medications:

o Currently on mood stabilizers, antidepressants, or other psychiatric medications? o History of medication noncompliance?

8. Diagnosis & Plan: o Likely bipolar disorder given symptoms. o Treatment could include medications (mood stabilizers, antipsychotics, therapy) and lifestyle modifications.

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:

1. Substance-Induced Mood Disorder o Given her alcohol use, it’s essential to rule out whether mood instability is a result of substance use or withdrawal. o Toxicology screening may help differentiate.
2. Major Depressive Disorder (MDD) with Impulsivity o If manic/hypomanic symptoms are not fully developed, she could have MDD with borderline personality traits. o Further assessment of mood duration and patterns is needed.
3. Attention-Deficit/Hyperactivity Disorder (ADHD) with Emotional Dysregulation

o Impulsivity and mood swings may suggest ADHD. o A history of childhood symptoms and executive dysfunction is needed.

4. Cyclothymic Disorder o If mood swings do not meet full criteria for Bipolar I or II, this may be considered.

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:

1. Psychiatric Referral – Comprehensive evaluation for mood disorder.
2. Medication Management: o Mood stabilizers: Lithium, valproate, or lamotrigine. o Atypical antipsychotics if severe mood symptoms (e.g., quetiapine, aripiprazole). o Avoid antidepressants alone, as they may trigger mania.
3. Psychotherapy: o Cognitive Behavioral Therapy (CBT) for mood regulation. o Dialectical Behavioral Therapy (DBT) if impulsivity is significant.
4. Substance Use Counseling: o Alcohol reduction strategies to prevent worsening symptoms.
5. Lifestyle Modifications: o Sleep hygiene, exercise, and stress management.
6. Laboratory Tests

Complete Blood Count (CBC)

✅ Results: Possibly low (linked to depression). ✅ Why?

 Deficiencies can contribute to fatigue, mood swings, and cognitive changes.

2. Psychiatric & Neurocognitive Tests

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).

3. Imaging (If Needed for Differential Diagnosis)

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.

3. Therapy & Psychosocial Support

✅ 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.

4. Substance Use Intervention

✅ 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.

5. Lifestyle Modifications

✅ 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.

6. Monitoring & Follow-Up

✅ 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.