In this assignment, you will review the Bipolar Interactive Case Study patient scenario and analyze the data to determine the health status of the patient.
Select the Patient Subjective Information tab. Within this tab, you will be able to watch a video to gain more insight regarding the patient as well as view important patient details.
For this assignment, you will
Your case study write up should include specific reference to relevant guidelines and other clinical information. The national guidelines should also be considered within treatment plans.
When you have completed viewing the patient information, download the Comprehensive Case Study Paper Template (Word) from the assignment page in Moodle. Use this document to complete the assignment and then submit it to the assignment drop box. Additionally, there is an Exemplar document for review to help guide your case study write up.
Works full time at a local metals factory as a line worker. Enjoys job very much. Widowed nine years ago—husband died suddenly in an MVA, (refuses to remove wedding band or clean out his belongings from home). Has two daughters, age 29 and 34, and one son, age 28. Six grandchildren.
Daughters live in same local, small town and visit often; son lives six hours away but visits as often as possible, she states. No illicit drug use, non-smoker, denies alcohol use.
Substance Use: Denies any use of nonprescription medication, denies use of tobacco or ETOH.
Trauma History: Denies any past history of trauma.
Spirituality: Catholic
Family History of Psychiatric Mental Illness: Unknown
Family History of Suicide: Denied
Denies any vaccines other than influenza received at Walgreens this past October.
Has lived in the United States for 39 years, U.S. citizen 15 years ago.
Has not traveled outside of country since moving here 39 years ago from Mexico.
Last pap 5 years ago—negative results.
Colonoscopy 3 years ago—several benign polyps.
Regularly wears seatbelt when riding as passenger
No weapons in the home
Reports usual health as “good as can be expected.” Denies fever, chills, weight changes.
Denies cough, dyspnea, or wheezing.
Denies past hx of asthma, recurrent infections.
Denies chest pain, palpitations.
Denies coordination problems, numbness, tingling, weakness, tremors. Denies seizures or frequent headaches. Not aware of memory problem. Denies h/o head injury.
Denies being depressed, not apathetic, slightly agitated and irritable when talking about her frustrations, denies euphoria, crying spells often, presence of significant stressors, difficulty getting up in the mornings.
Denies insomnia usually, difficulty falling asleep, no middle-night awakening, and disruption of 24-hour sleep cycle. Does not need a lot of sleep, recently.
No loss of interest or pleasure in activities, social isolation.
Denies feelings of helplessness, hopelessness, hostility, low self-esteem, guilt, lack of motivation, does miss husband, “sometimes when I miss him so much I feel guilty that I am still living.”
Denies feeling fatigued and reports she always had “high energy.”
Denies difficulty concentrating.
No increased or decreased appetite.
Denies delusions, hallucinations, feelings of persecution, preoccupation with religion but does relate “sometimes I think that people are talking about me.”
No self-inflicted injuries, no frequent thoughts of death, no lack of desire to continue living, no suicidal tendency.
No homicidal thoughts.
Denies interpersonal relationship problems except for family being “angry with her for constantly cleaning.” “Everyone enjoys spending time with me, I may be a bit stand offish at first.”
Daughter reports her mother is constantly cleaning out and reorganizing drawers and closets and is “throwing out things, stating she no longer needs them.” The daughter notes most things are not trash or unwanted, so she finds this odd behavior. Patient reports she is “not tired,” even without sleep, and “has a lot to do to welcome festivities for her granddaughter’s new baby arrival next year.” The daughter reports none of the grandchildren are “having babies.” The daughter is worried about her mother’s drastic change of behavior and attitude, which is becoming more tearful, irritable, and angry when they try to stop her from all the cleaning and organizing.
| Ht | 5’ 2” |
|---|---|
| Wt | 182 lbs. |
| T | 98.8 |
| P | 82 |
| R | 18 |
| BP | 130/80 |
| BMI | calculate at every visit |
60 y/o Hispanic woman who articulates clearly with a heavy Spanish accent, ambulates without difficulty, and is in no acute distress. General appearance same as stated age, normal level of personal hygiene; no inappropriate clothing, no bizarre personal appearance, no overly thin/overweight, no body odor.
Remainder of physical exam deferred during psychiatric mental health assessment.
A&Ox4, Appearance normal dress and appropriate, behavior speech appropriate. Thoughts coherent. Remote and recent memories intact.
Unable to sit without looking at clock, kicking legs, wringing hands. No abnormal mannerisms.
No noted tremors or tics; normal gait and stance; no involuntary movements.
Speech was clear, organized but moderately pressured.
Denies dysthymia, depression, dysphoria. Mildly irritable, frustrated with family.
Full ranging, not blunted, constricted, flat, incongruent with mood, inappropriate, labile, sad, tearful.
No language abnormalities; speech fluent; no dysphonia; no stuttering; language fluent and intact for naming, normal sentence structure.
Patient oriented X 4, no disorientation, short-term memory impairment, reduced abstraction ability, diminished cognitive functioning.
No deficiency on evaluation of connectedness; organized.
No thought content impairment; no suicidal ideation, homicidal ideations, paranoid ideations, poverty of thought, thought insertions, obsessions, irrational fears, delusions, hallucinations.
Slightly impaired insight and judgment, poor problem-solving and working memory about past histories. Avoids some questions about cleaning and sleep.
***No recent labs on file.