Patient’s initial – SM
Chief complaint: “I’ve dealt with this for as long as I can remember.”
Case : SM is a 29-year-old man, in a relationship with girlfriend, no children, living with a roommate in Bridgeport CT, undergraduate student and currently working as a personal trainer. SM report psychiatric history of depression and anxiety since early childhood but started seeing a therapist for these symptoms 2 years ago. Most recently, he was seeing a private provider in an outpatient practice who has now moved away from the area, so patient is in need of a new provider, which is what prompted him to reach out for treatment. Patient reports that he had been taking escitalopram for the past 4 month until 1 month ago at which point, he ran out. He reports that when he was taking the escitalopram, he felt dulled, emotionally numb, and unproductive. He mentions that he does not want to go back on the escitalopram. Furthermore, SM describes that beginning in early adolescence, he developed a pattern of cycling mood changes. He states that every two months or so he has period of days to weeks during which he is highly productive, staying up late working on multiple projects, having lots of idea, feeling very confident, reaching out socially. His friends and family would notice that he is acting differently and comment on it. However, when he is not in one of these episodes, SM reports feeling low, unmotivated, unfocused, and self-critical. He would also have attention difficulties when in his depressed state, and states that it’s hard for him to concentrate at work/school and he would prefer to stay inside and cancel his clients for the day. He reports passive SI and states that he has thoughts about once a month of “I don’t want to try this hard anymore.” He states that 1 year ago, he had thought of a method to crash his car while driving but stated that he did not want to put his family through that given that his sister attempted suicide and that there are more things he wants to do in life such as finishing school in which he majors in business management. He denies concrete suicidal plan or intent. SM also reports anxiety, characterized by anxious ruminations about expectations on himself and whether he is meeting them. He also states that he feels anxious about “wearing a mask” in social settings and ruminates about interpersonal situations such as “random things happening in the family or if I have an argument with my girlfriend”. He describes physical sensation of tension and restlessness. These anxious ruminations also make it hard for him to fall asleep and stay asleep. He rates the severity of his symptoms as a 9 on a 0-10 scale.
SM reports periods of depressed, low and unmotivated mood where he feels unfocused and self-critical. He reports anxious ruminations related to high self-expectations and random issues with his family or girlfriend. He reports physical sensation of tension. However, he denies ever having a panic attack or any episodes of intense fear. SM reports that he developed “extreme moods” in early adolescence but did not seek treatment until adulthood. He mentions cycling mood states with episodes of elevated mood, increased goal directed activity, decreased need for sleep and increased sociability alternating with episodes of low mood, amotivation and decreased concentration. He denies auditory or visual hallucinations. Further, SM reports that as a child he felt like a “shadow” and was left alone most times, however, denies any childhood traumas, nightmares or flashbacks. He denies any ritualistic or repeated behaviors. He reports decreased need for sleep when in his “up” mood and feels very energized with about 2 hours of sleep however, in his depressed states, he feels tired, fatigued and sleepy. He describes is sleep pattern as poor and inconsistent. He reports caffeine intake periodically, “may be once or twice a month” and states that he prefers to have orange juice in the morning as a way to start his day.
Mental status exam conducted : Age-appearing man, casually dressed, adequate grooming, cooperative, psychomotor normal, good eye contact, speech is monotone, mood is “low,” affect is subdued, no smiling noted, thought process is linear and goal directed,
thought content without current SI, insight and judgment are good as he can
describe symptoms and is treatment seeking, cognition is grossly intact.
Assignment
You diagnose patient with bipolar 2 disorder, current episode depressed, moderate severity, with Anxious distress ( F31.81) – Explain why you gave the patient this diagnosis based on the patient presentation and the DSM-5 criteria for bipolar 2 disorder. Give clear and very detailed rationale.
-Based on the patients’ presentation and DSM-5 criteria- What Two differential diagnoses would you give to this patient and why? Give clear and very detailed rationale. (Consider
clothymic Disorder(F34.0) and ADHD Predominatly inatentive type (F90.0) as the differential diagnosis)
-You order lamotrigine 25 mg daily for 2 weeks then increase to 50 mg daily for this patient. Why would you start at this dosage? Give clear detailed rationale for starting this medication. Also, explain medication use-Be sure to include separate paragraphs for Mechanism of action, common side effect/ adverse effect, black box warding and FDA approval/off label use.
-What education will you provide to the patient for starting this medication? (Write as if the patient is in your office and you were speaking to the patient directly) – be very specific and detailed.
-What TWO nonpharmacological interventions will you offer this patient. Why? – Be very detailed about each intervention and how it will help this patient. (Consider Cognitive behavioral therapy as one of the interventions and figure out a second nonpharmacological intervention for this patient. Write a well detailed rationale for each intervention and rationale as to why you choose it for the patient. Write a separate paragraph for each nonpharmacological intervention)
Be sure to include intext citations and multiple references!
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