Clinical Case Including the Significant Subjective and Objective Data
Case Study Jill, a 24 y/o Hispanic female arrives in the emergency room where her parents brought her for evaluation. They are worried because she is giving away all of her possessions and says she is planning to move to the South Pole so she can "save the world." Her parents say that she has hardly been sleeping at all for the last 7 days, but she seems very energetic. They say she has appeared to be "in a frenzy" lately. When you interview Jill you notice that she speaks very rapidly and is laughing uncontrollably. It is hard to get her to be quiet long enough for you to ask questions. She seems agitated and has difficulty sitting still.
Questions: Remember to answer these questions from your textbooks and clinical guidelines to create your evidence-based treatment plan. At all times, explain your answers.
1. Summarize the clinical case including the significant subjective and objective data.
2. Generate a primary and two differential diagnoses. Use the DSM5 to support the assessment. Include the DSM5 and ICD 10 codes.
3. Discuss a pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
4. Discuss non-pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
5. Describe a health promotion intervention that would be appropriate for this patient.
Case Analysis
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1 Summarize the clinical case, including the significant subjective and objective data.
This is a case of Jill, a 24-year-old female Hispanic, who was brought to the emergency room due to a delusion that she would save the world. Her parents elaborated that she has also experienced sleep dysfunction and increased energy and agitation for the past week. A mental state examination reveals that she has a flight of ideas.
2 Generate a primary and two differential diagnoses. Use the DSM5 to support the assessment. Include the DSM5 and ICD 10 codes.
Primary Diagnosis
1 Bipolar Disorder with Mania as the Current or Most Recent Episode. DSM-V Code 296.41, ICD-10 Code F31.11
Bipolar Disorder is characterized by mania preceded or followed by hypomania or a depressive episode. The individual should have the symptoms for most days of a week for at least one week. Mania is characterized by the following: First, this refers to the persistent elated feeling that the patient experiences for most of the days for at least one week. Second, the patient should experience at least three or at least four, if the patient is significantly irritable, of the following: 1) Exaggerated self-confidence or feelings of grandiosity; 2) Sleep dysfunction, as evidenced by the diminished need for rest; 3) Increased verbosity; 4) Flight of ideas; 5) Easily distractable by mundane things; 6) Psychomotor agitation or improved goal-directed activity in any situation. Alternatively, this may also be due to a purposeless non-goal-directed activity; 7) Unwarranted participation in activities that may cause significant harm to the individual. Third, the symptoms should have a considerable negative impact on the individual’s everyday activities. Lastly, the individual’s symptoms should not be another medical condition or an adverse effect of any form of substance. To be diagnosed with Bipolar I Disorder, the patient should have at least one of the symptoms enumerated in the second criteria in her lifetime. The hypomanic episode is not a prerequisite for the diagnosis (American Psychiatric Association, 2013, pp. 123-126).
Differential Diagnoses:
1 Bipolar II Disorder. DSM-V Code 296.29, ICD-10 Code F31.81
This disorder has almost the same criteria as Bipolar I Disorder. However, the differences include the following: For the first criterion, the elevated or persistently irritable mood can only be seen for four consecutive days and not for a week, unlike in Bipolar I Disorder. Second, unlike the third criterion of Bipolar I Disorder, this disorder should not significantly impact the individual’s social functioning. Moreover, it also has additional criteria compared to Bipolar I Disorder. These include the following: 1) The symptoms of an episode should be distinguishable compared when the patient is asymptomatic.; 2) The changes should be apparent to other people.; 3) The diagnosis is made when at least one hypomanic and one depressive symptom; 4) A manic episode should have never been manifested (American Psychiatric Association, 2013, pp. 132-134).
Although there are differences in the criteria, it is difficult to distinguish between Bipolar I and II due to the significant similarity of the symptoms. Nevertheless, in this patient, it was clearly stated that the symptoms have been present consistently for a week, and there was no depressive episode, making Bipolar II Disorder a close differential.
2 Attention-Deficit/Hyperactivity Disorder
This disorder is characterized by at least six symptoms of inattention or at least six symptoms of hyperactivity and the prominent symptoms of inattention in the patient. Conversely, the patient’s prominent symptoms of hyperactivity and impulsivity incl...