You are meeting with Julia Marie Groffin, a 38-year-old woman who is visiting the clinic because of a chief complaint of “not able to pay attention and not sleeping.”
Julia Marie enters your office and you notice that she is well-dressed, and her hygiene is good.
Julia Marie starts talking even before you offer her a seat. “My office is somewhat similar.” As she is sitting down, she says, “I am working on my MBA in finance. I have always been academically focused. You know my aim is to stay contemporary in my career and I enjoy going to school.
“Writing a romance novel energizes me, and that’s what I do for most of my weekend.” There is an incredible gush of joy as she is describing to you how she creates these fancy characters for her novel. “I imagine an ideal life for myself and then I create me as the main character in the novel. I design every situation and every character as picture perfect and I make this imaginative me in the novel enjoy the most desirable life. I really hope one day my romance novel will be made into a movie.
“Night school for MBA, writing romance novels on the weekends, all while working a full-time job as a certified public accountant! I have a busy life although I live by myself. I’ve had a lot of sexual partners recently, but I don’t want to get pregnant and so I take birth control pills.”
Julia Marie experiences periods of depression, where she says, “at those times, I think of hurting myself, but currently I don’t have any of those thoughts. But I get angry pretty easily.”
Julia Marie answers all your questions appropriately but is very distracted. However, you were able to engage her throughout the interview process.
From your perspective as Julia Marie’s psychiatric nurse practitioner, answer the following questions in a three-page double-spaced paper (not including the reference page) in APA format. Include at least three peer-reviewed, evidence-based references.
1. Pick a screening tool that would be most appropriate for Julia Marie and score it the best you can based on the information provided. Based on the screening tool and score, what would the most likely diagnosis for Julia Marie be? Include the scored screening tool as an appendix.
2. What interviewing techniques would be best used for Julia Marie?
3. What medication treatment would be best for Julia Marie? Please indicate the medication(s) you would start her on, the starting dose, and any patient education that you would need to do with these medications.
4. What type of therapy would work best for Julia Marie?
5. Identify what lab work you would order. Provide evidence to support your rationale
SOLUTION TO Julia Marie Groffin’s Case
- Pick a screening tool that would be most appropriate for Julia Marie and score it the best you can based on the information provided. Based on the screening tool and score, what would the most likely diagnosis for Julia Marie be?
Julia presents to the office with complaints of difficulty paying attention and not sleeping. In her history, she experiences an incredible gush of joy and explains that she experiences periods of depression. Based on the clinical presentation of the patient, the most appropriate tool for screening will be the mood disorder questionnaire (MDQ).
A mood disorder is a class of mental illnesses used broadly to describe all types of depression and bipolar disorders. Individuals with mood disorders experience distorted general emotional states and the mood is inconsistent with circumstances and can interfere with the ability to function. MDQ is recommended for the screening of patients presenting with signs of a mood disorder (Dumont et al., 2020). However, the tool does not provide conclusive results and comprehensive patient evaluation should be done following positive results. The tool contains 13 questions answered using a ‘YES’ or ‘NO’ response to determine if a patient has a mood disorder. Based on the response, the possibility for bipolar disorder will require the patient to score ‘YES’ in 7 or more questions, ‘YES’ to question 2, and ‘moderate or serious’ answer to question 3 of the MDQ.
Based on the assessment of the patient and answers from the MDQ screening test, Julia’s most likely diagnosis is bipolar disorder. Julia has an MDQ score of 12/13 in question 1 with a ‘YES’ response in question 2 and a ‘moderate problem’ answer in question 3. Julia’s MDQ response is available as an Appendix on the last page.
- What interviewing techniques would be best used for Julia Marie?
Julia appears distracted and has racing thoughts that could make an interview cumbersome. The first interview technique that can work for Julia is the selection of a quiet environment free from any external distractions. Creating a stress-free environment will calm the patient and allow time to address all questions. Another technique that can work is the use of closed-ended questions. This approach is recommended when restricting responses for consistency and accuracy. Julia is a talkative patient and asking open-ended questions is likely to make her go out of topic easily.
- What medication treatment would be best for Julia Marie? Please indicate the medication(s) you would start her on, the starting dose, and any patient education that you would need to do with these medications.
Medication is the key to stabilizing bipolar disorder. Based on Julia’s presentation, I will prefer to use Lamotrigine over first-line agents like carbamazepine and lithium because they are used for long-term management of the disease. Lamotrigine is used alone to treat seizures and is FDA approved as a maintenance treatment for patients with bipolar (McCormick et al., 2015). Lamotrigine helps in delaying the occurrence of mood episodes like mania or hypomania. I will start with a dose of 25mg PO twice daily and increase to 50mg per day after two weeks. I will then double the dose every two weeks until a dose of 200mg per day is reached. Patient education will involve side effects of the drug like skin rash and the effects of rapid withdrawal like worsened mania or depression.
- What type of therapy would work best for Julia Marie?
The best therapy that I would recommend for Julia is cognitive-behavioral therapy (CBT). This type of therapy focuses on the relationship between the patient’s thoughts, feelings, and behaviors. It is effective in addressing depressive symptoms that occur periodically, addressing feelings of guilt and negative thoughts, and feelings of losing friends or relationships (Novick & Swartz, 2019). The primary goal of CBT is to teach the patient how to approach thoughts differently so that when they come, one does not buy-in or believe in their negativity. CBT will help Julia in managing her anger and address the patterns like multiple sex partners that are a result of her condition.
- Identify what lab work you would order. Provide evidence to support your rationale.
There are no specific blood tests that can be used to diagnose bipolar disorder. However, laboratory tests may be performed to rule out medical conditions that can present with similar symptoms. I would like to order a complete blood count (CBC) to rule out anemia that can cause depression in bipolar or mania. CBC will also indicate the level of white blood cells and can guide treatment with lamotrigine because anticonvulsants can cause bone marrow suppression (McCormick et al., 2015). I would also order thyroid function tests to assess for hyperthyroidism or hypothyroidism (Li et al., 2019). The most common features of thyroid dysfunction include anxiety and depression which are also observed in bipolar patients.
Dumont, C. M., Sheridan, L. M., Besancon, E. K., Blattner, M., Lopes, F., Kassem, L., & McMahon, F. J. (2020). Validity of the Mood Disorder Questionnaire (MDQ) as a screening tool for bipolar spectrum disorders in anabaptist populations. Journal of Psychiatric Research, 123, 159-163. https://doi.org/10.1016/j.jpsychires.2020.01.011
Li, C., Lai, J., Huang, T., Han, Y., Du, Y., Xu, Y., & Hu, S. (2019). Thyroid functions in patients with bipolar disorder and the impact of quetiapine monotherapy: A retrospective, naturalistic study. Neuropsychiatric Disease and Treatment, 15, 2285. https://doi.org/10.2147/NDT.S196661
McCormick, U., Murray, B., & McNew, B. (2015). Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. Journal of the American Association of Nurse Practitioners, 27(9), 530–542. https://doi.org/10.1002/2327-6924.12275
Novick, D. M., & Swartz, H. A. (2019). Evidence-based psychotherapies for bipolar disorder. FOCUS, A Journal of the American Psychiatric Association, 17(3), 238-248. https://doi.org/10.1176/appi.focus.20190004
Julia Marie Groffin’s MDQ
Question 1:Has there ever been a period of time when you were not your usual self and…
1.you felt so good or so hyper that other people thought you were not your
normal self or you were so hyper that you got into trouble? Yes No
- you were so irritable that you shouted at people or started fights or arguments? Yes No
- you felt much more self-confident than usual? Yes No
- you got much less sleep than usual and found you didn’t really miss it? Yes No
- you were much more talkative or spoke much faster than usual? Yes No
- thoughts raced through your head or you couldn’t slow your mind down? Yes No
- you were so easily distracted by things around you that you had trouble concentrating or staying on track? Yes No
- you had much more energy than usual? Yes No
- you were much more active or did many more things than usual? Yes No
- you were much more social or outgoing than usual, for example, you ” “
telephoned friends in the middle of the night? Yes No
- you were much more interested in sex than usual? Yes No
12.you did things that were unusual for you or that other people might have
thought were excessive, foolish, or risky? Yes No
13.spending money got you or your family into trouble? Yes No
Question 2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? Yes No
Question 3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights? No Problem Minor Problem Moderate Problem Serious Problem
Question 4.Have any of your blood relatives (i.e. children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? Yes No
Question 5.Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? Yes No
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