What other psychotic-related diagnosis can PMHNP assign to A.J. based on her mental health history?
1: what other psychotic-related diagnosis can PMHNP assign to A.J. based on her mental health history?
2:What other mood stabilizer(s) can be used to treat A.J.’s Bipolar I depression?
THE ASSIGNMENT
Please read week 9 presentation SOAP note (file attached), and please respond to the following questions in two different discussions , ½ to 1 page each with at least 2 peer-reviewed references each.
1: what other psychotic-related diagnosis can PMHNP assign to A.J. based on her mental health history?
2:What other mood stabilizer(s) can be used to treat A.J.’s Bipolar I depression?
LEARNING RESOURCES
Required Readings
• Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.
o Chapter 14, “Dementia” (pp. 146–147 only)
• Office of Disease Prevention and Health Promotion. (n.d.). Social Determinates of Health.Links to an external site. Healthy People 2030. U.S. Department of Health and Human Services. https://health.gov/healthypeople/priority-areas/social-determinants-health
• Stahl, S. M. (2021a). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.
o Chapter 12, “Dementia: Causes, Symptomatic Treatments, and the Neurotransmitter Network Acetylcholine”
Required Media:
• American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adultsLinks to an external site.. Journal of the American Geriatrics Society, 67(4), 674–694. https://doi.org/10.1111/jgs.15767
Links to an external site.
• Chisolm , M. S., & Payne, J. L. (2016). Management of psychotropic drugs during pregnancyLinks to an external site.. British Medical Journal, 352. https://doi.org/10.1136/bmj.h5918
Subjective
CC (chief complaint): “My family is driving me crazy. I am angry, and I do not need sleep.
Jesus already told me I would be victorious.”
HPI: A.J. is a 70-year-old African American older adult who presented to the clinic for a
worsening psychiatric condition. She traveled out of state to visit his son in prison and has not
been compliant with her medications. A.J. had been institutionalized for psychosis episodes due
to major depression, PTSD, Schizophrenia, and SUD in the past. She survived an attempted
murder by her ex-husband 20 years ago, which made her develop Post-traumatic Stress Disorder.
She had had a recurrent episode of manic episodes whenever she visited her only son in prison.
A.J. stated that her sister was driving crazy and blamed her for not taking care of her son when
she was in rehab for involuntary commitment due to SUD and past psychiatric conditions.
Medically, A.J. has a history of CHF, Diabetes, and severe osteoarthritis and ambulates with a
cane.
Substance Current Use: Daily cannabis, ETOH abuse, and started drinking 2 bottles of Bud
light nightly. 1/2 Pack per day smoking
Medical History: CHF, Morbid Obesity, and Obstructive Sleep Apnea. (CPAP noncompliance), COPD
Family Mental History: Unknown
Current Medications: Olanzapine 15mg, sertraline 100mg, Trazodone 50mg, and Prazosin
5mg, Glipipizide/Metformin 2.5mg/250mg
Allergies: NKDA
• Reproductive Hx: Older Adult. She has a son and lost her daughter to gun violence.
ROS:
2
GENERAL: HR 100, BP 145/89, R.R. 24, BMI 43 (HT62 “, wt 235 Іb)
HEENT: Eyes: Wears glasses. No car, nose, and throat problem
CARDIOVASCULAR: CHF, Hyperlipidemia, and Sinus Arrhythmia
RESPIRATORY: Unlabored breathing, Sleep apnea, and uses CPAP occasionally.
GASTROINTESTINAL: Occasional constipation
GENITOURINARY: Overactive bladder with leakage
NEUROLOGICAL: No neurological deficit
MUSCULOSKELETAL: Osteoarthritis of the knee and hips and ambulates with a cane
HEMATOLOGIC: No blood cancer or hematological conditions
LYMPHATICS: No edema
ENDOCRINOLOGIC: Diabetes Type 2
Objective
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Mental Status Assessment
70-year-old African American older adult who presented to the clinic this month because
of her worsening mental health condition. She dressed too warm for the weather with layer
clothes and a rain jacket. Her granddaughter accompanied her on this visit. A.J. was angry at her
sister and blamed her for things going wrong in her life. Her speech was pressured, and she was
agitated and restless. She stated with conviction,” My family is driving me crazy. I am angry, and
I do not need sleep. Jesus already told me I would be victorious.” Her granddaughter said she
was depressed for most of her trip out of state and sometimes had hypersomnia. A.J.’s thought
process is fleeing, and she sometimes loses her thought. She admitted to not taking her
medications because she forgot to pack them when she traveled. She appears to have neglected
her activities of daily living, with a pungent smell that seems to be from incontinence of urine.
4
Differential Diagnostic Impressions
Bipolar I Disorder With mood-congruent psychotic features 31.12)
Diagnosing A.J. with Bipolar I disorder appears to be straightforward. People with Bipolar one
often has extreme mood swings with the hallmark manic symptomatology, then periods of
extreme depressive symptoms( Farhad et al., 2023). A.J. demonstrated symptoms of this
condition with objective assessments of pressured speech and gracious beliefs. She also shows a
decreased need for sleep and excessive agitation and restlessness, which are classic signs of
manic episodes. She also appears to have neglected her physical appearance and did not focus on
her hygiene. In addition, A.J. had a history of Bipolar I with psychotic features that landed her in
a psychiatric inpatient facility in the past.
Post Traumatic Stress Disorder (PTSD) (F43.10)
A.J. had a death-life experience when she survived the assassination attempt in her life by her exhusband. Post-traumatic Stress Disorder is a complex psychiatric condition that is linked to a
traumatic event that leads to constant reprocessing and reliving of the traumatic experience,
avoidance of trauma-related stimuli, and negative alterations in cognition and mood. (Thibodeau
& Merges, 2024). A.J. had a history of PTSD with recurrent nightmares. She was on Prazosin to
manage her symptoms before the lapse in compliance. Her lack of sleep might be related to the
avoidance of the nightmares she was having. In addition, A.J. has a comorbid diagnosis of
obstructive sleep apnea, which could be life-threatening depending on the severity.
Substance Use and Alcohol Disorder (F10.129)
Women who struggle with substance use disorder and alcohol use disorder often have many risk
factors in common, like violence from sexual partners, other mental health disorders, and
sometimes poverty. (Jackson et al., 2023). A.J. had a history of violent exposure to her ex-
5
husband; she also had a significant psychiatric history, including schizophrenia and nicotine
dependence. She uses cannabis recreationally, even though the use of marijuana has a direct link
to mental health disorders (Yau et al., 2019), let alone somcone who uses it recreationally. A.J.
has a significantly higher risk factor for substance use disorder and had been hospitalized
involuntarily in the past due to alcohol dependence.
Reflections
Another differential diagnosis for A.J. is schizophrenia. She does have a history of the condition,
but her symptoms have been well-managed in the past. A.J. has complex psychiatric
comorbidities and an extensive medical history, which make managing her condition somewhat
challenging for clinicians. Her refusal to be compliant with her CPAP machine use makes
arriving at a straightforward diagnosis challenging. How long has she been unable to have restful
sleep due to obstructive sleep apnea? Untreated obstructive sleep apnea can contribute to rightsided heart failure. She has already been diagnosed with congestive heart failure(CHF). It is
unclear about the treatment she is receiving from primary care and a cardiologist with regard to
her heart failure. A.J.’s disability and lack of formal education appear to be a contributing factor
to non-compliance with treatment and medication adherence. Poor living standards, smoking,
and poor head condition make managing her psychiatric condition more difficult. Social work
consults and interdisciplinary teams must work together for better disease management.
Case Formulation and Treatment Plan
A.J. needs a comprehensive medical workup to address her overall health and a referral to
cardiologist regarding managing her cardiac condition. She needs a sleep study referral to get a
better fit for her CPAP machine. Laboratory tests for baseline include a basic metabolic Panel,
Hemoglobin A1c, CBC, Liver function test, and Albumin level due to her alcohol consumption.
Pharmacotherapeutic Intervention
Continue with her current medication, which was effective in the past, but increase
Olanzapine to 20mg PO daily, sertraline 100mg PO daily, Trazodone 50mg QHS (
effective in some insomnia), Prazosin 5mg( to help with nightmares),
Glipipizide/Metformin 2.5mg/250mg( Diabetes).
Add Depakote 250mg P.O. daily for mood because of Bipolar I diagnosis. Check the level
after 2 months
A follow-up visit in a week
Non-Pharmacotherapy Interventions
Psychotherapy, especially trauma-focused therapy, does address the recurrent A.J.’s
nightmares and PTSD, and CBT to help her with coping mechanisms and learn how to
deal with her emotions when visiting her son in prison.
A.J. needs an outpatient psychiatric rehabilitation program to help her manage her
psychosis symptoms
Family Therapy: To help her and family to educate them about mental health diagnosis
and disease management,
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