Review the Bipolar Case Study patient scenario and analyze the data to determine the patient’s health status.
For this assignment
Inpatient and Outpatient Psychiatric/Mental Healthcare
Past Psych Diagnosis (es): MDD and GAD
Treatments:
Works at a nursing home as a CNA full-time. Enjoys her job very much. Widowed nine years ago: husband died suddenly in an MVA. 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. History of smoking—1 pack/day x 18 years—quit: last 12 years ago—has not resumed. Drinks two to four glasses of wine on Friday evenings only. No illicit drug use.
Substance Use: Denies any use of nonprescription medication.
Trauma History: Denies any history of trauma.
Spirituality: Catholic
Regularly wears seatbelt when driving and as passenger.
No weapons in the home.
Reports usual health as “good as can be expected.” Denies fever, chills, weight changes.
Denies chest pain, palpitations.
Denies coordination problems, numbness, tingling, weakness, tremors. Denies seizures or frequent headaches. Not aware of memory problems. Denies history of 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 behavior odd. Patient reports she is “not tired,” even without sleep, and “has a lot to do to prepare for the welcome festivities for her granddaughter’s new baby's 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 cleaning and organizing.
| Height | 5’ 2” |
|---|---|
| Weight | 182 lbs. |
| T | 98.8 |
| P | 82 |
| R | 18 |
| BP | 124/82 |
| BMI | calculate at each visit |
60-year-old 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 body odor.
Remainder of physical exam deferred during psychiatric mental health assessment.
A&O x 4, 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.