Bipolar Disorder Case Study

Case Study:
BACKGROUND INFORMATION
The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder. Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?” She weights 110 lbs. and is 5’ 5” SUBJECTIVE
Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.” You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.

Genetic testing reveals that she is positive for CYP2D6*10 allele. Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago. MENTAL STATUS EXAM The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation. The Young Mania Rating Scale (YMRS) score is 22

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Decision Point One Select what you should do: (I got three options, I selected the first one)
– Begin Lithium 300 mg orally BID. (I SELECTED THIS ONE BECAUSE PATIENT SAID SHE DIDN’T TAKE IT WHEN WAS INITIALLY PRESCRIBED, SO WE CANNOT ASSUME THIS SPECIFIC MEDICATION DOESN’T WORK FOR HER).
– Begin Risperdal 1 mg orally BID ***OPTION NOT TAKEN* DISREGARD
– Begin Seroquel XR 100 mg orally at HS ***OPTION NOT TAKEN- DISREGARD

RESULTS OF DECISION POINT ONE:
– Client returns to clinic in four weeks
– Client informs you that she has been taking her drug “off and on” only when she “feels like she needs it”
– Today’s presentation is similar to the first day you met her

Decision Point Two Select what you should do next: (I selected the second one)
– Increase Lithium to 450 mg orally BID (**OPTION NOT TAKEN- DISREGARD
– Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology (I SELECTED THIS ONE BECAUSE SWITCHING HER TO A DIFFERENT MEDICATION OR INCREASING THE CURRENT DOSE WILL NOT SOLVE THE PROBLEM. I NEED TO EDUCATE HER ABOUT THE MEDICATION AND WHY SHE CAN’T STOP TAKING IT).
– Switch to Depakote ER 500 mg orally at HS (**OPTION NOT TAKEN- DISREGARD
RESULTS OF DECISION POINT TWO
– Client returns to clinic in four weeks
– Client states that the drug makes her nauseated and gives her diarrhea
– Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again

Decision Point Three Select what you should do next: (I selected the second one)
– Change to Depakote ER 500 mg at HS
– Change Lithium to sustained release preparation at same dose and frequency(I SELECTED THIS ONE BECAUSE LITHIUM IS THE BEST TREATMENT FOR BIPOLAR, AND GIVEN SUSTAINED RELEASE PREPARATION WILL DO THE SAME GOOD EFFECT WITHOUT THE SIDE EFFECTS PATIENT IS COMPLAINING NOW.
– Change to trileptal 300 mg orally BID

My reasoning behind this decisions are because:

the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.

I need the paper to include:

an explanation of the psychological disorder presented ***BIPOLAR DISORDER*** and the decision steps you applied in completing the interactive media piece for the psychological disorder you selected. Then, explain how the administration of the associated pharmacotherapeutics you recommended may impact the patient’s pathophysiology. How might these potential impacts inform how you would suggest treatment plans for this patient? Be specific and provide examples.

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