Mood Stabilizer Case Study

Subjective:

CC: “I cannot shake my poor mood”

HPI: RL is a 27 year old female who works in a local cafe. She has a psych history but usually when she is having a mood she rarely sleeps and has a lot of energy; however, for the last month she severely depressed without suicide ideation, has called off work nearly every day, no longer seeing her friends. She is referred to you from the PCP for ‘excessive depression.’ She claims to have been taking her medications as prescribed.

He comes to visit you for an initial visit at the discretion of his boss.

Objective

PMH:
Axis 1: Bipolar 1 (diagnosed 3 year prior)
Axis 2: None
Axis 3: HTN
Axis 4: Work-related stress
Axis 5: 45

FH: Father: Bipolar
Mother: None

SH: Alcohol: Beer after work with friends (1-2x/week; however, not recently)
Tobacco: 1-2 cigs/day
Illicit drugs: Denies
Living: Lives with high school friend in apartment in a trendy part of town.

All: None

Vaccination History:
Up to date

Medications:
Lithium 300mg PO BID
Amlodipine 5mg PO daily
Vitals (from today): BP 122/78 (sit) HR 57 Ht: 5’2” Wt:115 pounds
PE: HEENT: PERRLA; moist mucous membranes
CV: RRR, S1 and S2 WNL, no S3 or S4
Pulmonary: Lungs CTA
Abdomen: (+) BS, NTND
Ext: No edema to extremities
Neuro: A&O x 3, appears depressed

Labs(today):
142|102|10/82
3.9| 24|0.8 TSH: 2.1
ALT: 15 units/L AST: 15 units/L alk phos: 35 units/L
GFR: 105ml/min/m2
Lithium: 1.0 mEq/L
QTc: 350ms

Assessment
1. What is your assessment of this patient’s new psychiatric disorder? Justify your assessment.
Plan

Non-Medication Therapy / Referrals
2. What non-medication recommendations or referrals would you make for this patient’s new psychiatric disorder?

New Medication Therapy
3. Please fill out the below prescription with your recommended medication(s) for the patient’s new psychiatric disorder (copy and paste new prescriptions if writing more than one prescription):

SLU NURS 543 Fake Medical Home and Associates
123 Main St. St. Louis, MO
314-555-8800

Name___________________________________ Age/DOB___________

Address_____________________________ Date______

Rx:
Signature:____________ Signature:__________________________
Substitution Permitted Dispense as Written

Refills_________ DEA number: _______________

4. Justify your recommendation above:

5. List two other potential treatments for this patient’s mood disorder and discuss why (no more than two reasons) you did not select each:

Potential Treatment Reason not selected
6. What TWO (2) patient or disease specific factors which, if present, would lead you to not select your recommended treatment above in the prescription (Question 3) and why?

7. What are TWO (2) potential medication interactions (major) with your recommended treatment in question 3? (the patient does not need to be currently taking interacting medications) Discuss the impact of the interactions if taken together.

Monitor 

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8. List three symptoms, three physical findings and three lab parameters you would want to monitor for your medication recommendation above in question 3 AND/OR the patient’s psychiatric disorder as well as the frequency and rationale for the monitoring

Parameter Frequency Rationale
Symptoms

Physical findings

Lab findings

Educate/counsel

9. Educate the patient of THREE (3) specific points on regarding the medication you’re your prescribed (eg, common ADRs, time to efficacy, administration issues, etc)  CLICK HERE TO ORDER THIS ESSAY!!!!