- Admission Date: 9/10/2018
- Name J. D.
- DOB: 4/5/1990
- Sex: Female
- Allergies: None
- Language: English
- VS: BP 130/98, HR 74, Respirations 19, Pulse Ox 98%
Chief Complaint: The patient is concerned with reoccurring hypomania episodes and depression.
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The patient was admitted after a suicide attempt, which was interrupted by her sister. The episode followed after a prolonged depression that J.D. has had for a few weeks. She is a twenty-eight years old female of Caucasian ethnicity, well-groomed and well presented. J.D. admitted that previously she had experienced severe depression due to being fired from her job. She stated that she has reoccurring mood swings (from a state in which she feels “extremely happy and confident in herself” to being depressed for weeks, both without a particular reason). However, she stated that the condition never bothered her seriously until recently. Currently, she is melancholic, however, emphasized that she regrets trying to commit suicide.
J. D. has never been treated for a psychiatric condition; however, her sister indicated that “she has shown symptoms ever since she was a kid.” J. D. admitted to experiencing episodes of unexplained excitement followed by depression throughout her life. Recent stress could have served as a trigger to the condition, while J. D. stated that previously she had managed to “control her state on her own” thus, she did not seek treatment from a professional. The absence of the previous hospitalization indicates that J.D. experiences hypomania, which is less severe than mania and is more difficult to diagnose.
- Hx of Violence to others: Has no history of violence towards people
- Previous Treatment: No
- IOP: 0
- PHP: 0
- Previous Psychiatric Hospitalizations: 0
J. D. moved in with her sister about three months ago, after she was fired from her job. Her mother lives in Texas, while her father is unknown. The patient’s mother had been hospitalized due to mania episodes several times; however, they do not talk to each other; thus, she is unsure of the diagnosis. J. D. reports no history of abuse or trauma during childhood. Prior she used to work at a restaurant where she fought with a client. The patient does not admit to having a substance abuse history.
Legal HX: None
Med/Surgical HX: N/A
Mental Status Exam: The patient is well presented, groomed, with adequate speech, and good eye contact. She denies previous mental health issues or substance abuse problems.
Primary Psychiatric diagnosis: Bipolar II, reoccurring depression – DSM 296.89
Current intervention plan includes medication and therapy to stabilize the state. The anticipated outcome is the ability to control mood swings and the absence of depression episodes. Fluoxetine – to minimize the effects of depression and Lithium – for mood swings control. Cognitive-behavioral therapy to help the patient manage the condition. The patient has stated that she understands the diagnosis and agrees to take prescribed treatments.
Labs: Blood levels of lithium, kidney functioning, and thyroid functioning.
The reason why I chose this case is that the patient had not been treated for her bipolar disorder. The effects caused by lack of treatment are present as she is experiencing severe depression and hypomanic episodes. The condition could have been triggered by work and personal life stress, which worsened the symptoms. An interesting aspect is that the patient had experienced symptoms of bipolar since childhood; however, those were neglected, and thus her mental health state is severely compromised. Both the personal and professional life of J. D. are endangered due to the issue.
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- Are there any studies that examine the effects of untreated bipolar disorders on both the physical and mental health of a person?
- Is there any evidence that cases of neglected bipolar (those which include severe depression and mania) should have a different intervention plan, which would be more effective in treating the condition (when compared to standard treatment)?