NR602 I HUMAN CASE WEEK 6
SARAH JAMIESON WHO
PRESENTS FOR MOOD
ASSIGNMENT
CHAMBERLAIN UNIVERSITY
2025
Patient History: Sarah Jamieson
1. Chief Complaint (CC):
o Presents with mood instability, depressive episodes,
and impulsive behaviors.
2. History of Present Illness (HPI):
o Reports ongoing mood swings for several years.
o Episodes of elevated mood with increased energy, reduced
need for sleep, and impulsive decisions.
o Alternating periods of depression, low energy, and
feelings of hopelessness.
o Engages in risky behaviors, including alcohol use.
3. Past Psychiatric History:
o Possible previous diagnosis of bipolar disorder or related
mood disorder.
o History of depressive and manic/hypomanic episodes.
o Possible prior psychiatric hospitalizations or therapy.
4. Medical History:
o No major physical health concerns reported
(unless specified).
o Any history of substance use affecting mental health?
5. Family History:
o Family history of mood disorders, such as bipolar disorder
or depression?
o Any genetic predisposition to mental health conditions?
6. Social History:
o Possible stressors, including work, relationships, or
financial issues.
o History of substance use (alcohol).
o Support system – family, friends, or therapy?
7. Medications:
oCurrently on mood stabilizers, antidepressants, or
other psychiatric medications?
o History of medication noncompliance?
8. Diagnosis & Plan:
o Likely bipolar disorder given symptoms.
o Treatment could include medications (mood stabilizers,
antipsychotics, therapy) and lifestyle modifications.
Physical Exam for Sarah Jamieson
A physical exam in the context of a psychiatric evaluation is primarily
used to rule out medical conditions that might contribute to mood
instability. Below is a structured physical exam based on Sarah
Jamieson's case:
General Appearance:
Well-groomed or disheveled?
Signs of psychomotor agitation (restlessness, excessive
movement) or retardation (slow movements, low energy)?
Eye contact: appropriate, poor, or intense?
Vital Signs:
Blood Pressure (BP): Elevated or within normal
range? (Hypertension could indicate anxiety or
stimulant use.)
Heart Rate (HR): Elevated in mania, anxiety, or stimulant use.
Respiratory Rate (RR): Normal vs. increased (could
indicate anxiety or substance withdrawal).
Temperature: Rule out fever (infection-related causes of
delirium).
Weight/BMI: Any significant weight loss/gain (suggestive
of depression, metabolic issues, or medication side effects)?
Neurological Exam:
Cranial Nerves: Intact or deficits? (Rule out neurological
causes of mood swings.)
Reflexes: Hyperreflexia in anxiety or stimulant use,
normal otherwise.
Tremors or Involuntary Movements: Could indicate
medication side effects (e.g., lithium toxicity, antipsychotic-
induced tremors).
Gait and Coordination: Any instability (suggests alcohol effects,
neurological conditions)?
Psychiatric/Mental Status Exam (MSE):
Mood: Patient-reported (elevated, depressed, irritable).
Affect: Congruent with mood or inappropriate?
Speech: Rapid and pressured (mania) vs. slowed (depression).
Thought Process: Logical vs. racing thoughts, flight of ideas.
Perception: Any hallucinations or delusions?
Insight & Judgment: Impaired (impulsivity, risky behaviors) or
intact?
Skin Examination:
Signs of self-harm (scars, burns, scratches)?
Needle marks or bruising (if substance use is suspected)?
Sweating (possible withdrawal or medication side effect)?
Abdominal Exam:
Liver enlargement/tenderness? (Chronic alcohol use may lead
to liver disease.)
Endocrine Assessment:
Thyroid enlargement or nodules? (Hyperthyroidism can mimic
mania, and hypothyroidism can mimic depression.)
Summary & Clinical Considerations:
Key psychiatric signs: Pressured speech, impulsivity,
mood lability, risky behaviors.
Rule out medical conditions like thyroid dysfunction,
substance withdrawal, or neurological issues.
Next steps: Further psychiatric assessment, lab tests (thyroid
function, liver enzymes for alcohol use, drug screening if needed).
Assessment: Sarah Jamieson
Primary Diagnosis: Bipolar Disorder (Likely Type I or II)
Based on Sarah Jamieson’s history, symptoms, and physical exam
findings, the most likely diagnosis is Bipolar Disorder due to the
presence of:
Manic/hypomanic episodes (elevated mood, impulsivity,
risky behaviors, decreased need for sleep).
Depressive episodes (low mood, depression, possible substance
use as self-medication).
Mood cycling over time.
Risky behaviors, including alcohol use.
Differential Diagnoses:
1. Substance-Induced Mood Disorder
o Given her alcohol use, it’s essential to rule out whether
mood instability is a result of substance use or withdrawal.
o Toxicology screening may help differentiate.
2. Major Depressive Disorder (MDD) with Impulsivity
o If manic/hypomanic symptoms are not fully developed,
she could have MDD with borderline personality traits.
o Further assessment of mood duration and patterns is needed.
3. Attention-Deficit/Hyperactivity Disorder (ADHD) with
Emotional Dysregulation
o Impulsivity and mood swings may suggest ADHD.
o A history of childhood symptoms and executive
dysfunction is needed.
4. Cyclothymic Disorder
o If mood swings do not meet full criteria for Bipolar I or II,
this may be considered.
Risk Assessment:
Suicidal Ideation: Any history of self-harm or suicide attempts?
Homicidal Ideation: Any aggressive behavior towards others?
Substance Use: Alcohol use may exacerbate mood instability.
Plan & Next Steps:
1. Psychiatric Referral – Comprehensive evaluation for
mood disorder.
2. Medication Management:
o Mood stabilizers: Lithium, valproate, or lamotrigine.
o Atypical antipsychotics if severe mood symptoms (e.g.,
quetiapine, aripiprazole).
o Avoid antidepressants alone, as they may trigger mania.
3. Psychotherapy:
o Cognitive Behavioral Therapy (CBT) for mood regulation.
o Dialectical Behavioral Therapy (DBT) if impulsivity
is significant.
4. Substance Use Counseling:
o Alcohol reduction strategies to prevent worsening symptoms.
5. Lifestyle Modifications:
o Sleep hygiene, exercise, and stress management.
1. Laboratory Tests
Complete Blood Count (CBC)
◻ Results: Normal (unless anemia or infection present)
◻ Why? Screens for anemia or infections that may contribute to fatigue
and low energy.
Comprehensive Metabolic Panel (CMP)
◻ Results:
Liver function tests (AST/ALT): May be elevated due to alcohol
use.
Kidney function (BUN/Creatinine): Normal unless medication
toxicity.
Electrolytes (Sodium, Potassium, Calcium): Normal (imbalances
can cause mood symptoms).
Thyroid Panel (TSH, Free T4/T3)
◻ Results: Normal (unless underlying thyroid disorder).
◻ Why?
Hyperthyroidism can mimic mania (elevated mood, insomnia,
impulsivity).
Hypothyroidism can mimic depression (low energy, mood
instability).
Toxicology Screen (Urine Drug Test, Alcohol Level)
◻ Results:
Positive for alcohol (if currently using).
Negative for other substances unless additional substance
use suspected.
◻ Why?
Rules out substance-induced mood disorders.
Vitamin D & B12 Levels
◻ Results: Possibly low (linked to depression).
◻ Why?
Deficiencies can contribute to fatigue, mood swings, and
cognitive changes.
2. Psychiatric & Neurocognitive Tests
Mood Disorder Questionnaire
(MDQ)
◻ Results: Positive for Bipolar Disorder (meets threshold for
manic/hypomanic symptoms).
◻ Why?
Screens for bipolar symptoms and severity.
Montreal Cognitive Assessment (MoCA) / Mini-Mental State Exam
(MMSE)
◻ Results: Normal cognitive function.
◻ Why?
Rules out cognitive impairment (e.g., alcohol-related brain
changes).
3. Imaging (If Needed for Differential Diagnosis)
Brain MRI / CT Scan
◻ Results: Normal (unless structural abnormalities).
◻ Why?
Used only if there are neurological symptoms (seizures, memory
loss, head trauma history) to rule out organic brain disease.
Summary of Test Findings:
Likely Findings:
o Liver function abnormalities (AST/ALT elevated due
to alcohol use).
o Positive Mood Disorder Questionnaire (MDQ) –
Suggestive of Bipolar Disorder.
o Possible Vitamin D or B12 Deficiency.
o Negative Urine Drug Screen (except alcohol, if
recently consumed).
o Thyroid function normal (unless underlying issue).
Diagnosis: Sarah Jamieson
Primary Diagnosis:
◻ Bipolar I Disorder (Most Likely) – F31.81 (ICD-10 Code)
◻ Rationale:
History of mood cycling between manic/hypomanic episodes
(elevated mood, impulsivity, risky behaviors) and depressive
episodes (low mood, alcohol use, withdrawal).
Symptoms of mania/hypomania (impulsivity, decreased need for
sleep, risky behaviors).
No evidence of alternative medical conditions causing
mood swings.
Differential Diagnoses:
1◻⃣ Substance-Induced Mood Disorder (Alcohol-Related) – F10.24
Mood instability could be worsened by alcohol use.
Requires further assessment of alcohol’s role in symptoms.
2◻⃣ Major Depressive Disorder (MDD) with Impulsivity –
F33.1
If manic symptoms are less severe or do not meet criteria for
Bipolar I, MDD with impulsivity or borderline personality
traits could be considered.
3◻⃣ Attention-Deficit/Hyperactivity Disorder (ADHD) – F90.2
Impulsivity and mood swings could overlap with ADHD, but
presence of distinct mood episodes suggests bipolar disorder
instead.
4◻⃣ Cyclothymic Disorder – F34.0
If mood fluctuations are chronic but do not meet full Bipolar I or
II criteria, this could be an alternative.
Final Diagnostic Impression:
◻ Bipolar I Disorder with Current or Most Recent Episode
Manic (F31.81)
◻ Alcohol Use Disorder, Moderate (F10.20) – If alcohol is
significantly affecting mood and behavior
Plan for Sarah Jamieson
1. Psychiatric Management
◻ Referral to Psychiatry for further evaluation and medication
management.
◻ Monitor mood cycles and symptoms to track patterns and severity.
2. Medication Management
◻ Mood Stabilizers:
Lithium (first-line for bipolar disorder, reduces mania and suicide
risk).
Valproate (Depakote) (alternative if lithium is contraindicated).
Lamotrigine (Lamictal) (better for bipolar depression).
◻ Atypical Antipsychotics:
Quetiapine (Seroquel), Aripiprazole (Abilify) (for acute mania
and maintenance).
◻ Avoid Antidepressants Alone – Can trigger manic episodes.
If depression is severe, SSRIs may be added cautiously with
a mood stabilizer.
3. Therapy & Psychosocial Support
◻ Cognitive Behavioral Therapy (CBT): Helps with mood regulation
and coping strategies.
◻ Dialectical Behavioral Therapy (DBT): Useful if impulsivity and
risky behaviors are prominent.
◻ Psychoeducation: Teach Sarah about bipolar disorder, medication
adherence, and mood tracking.
4. Substance Use Intervention
◻ Alcohol Use Counseling: Assess for Alcohol Use Disorder (AUD)
and provide support.
◻ Motivational Interviewing: Encourage reducing alcohol intake to
stabilize mood.
◻ Support Groups: Recommend Alcoholics Anonymous (AA) or
SMART Recovery.
5. Lifestyle Modifications
◻ Sleep Hygiene: Establish consistent sleep schedule (important for
bipolar stability).
◻ Exercise & Diet: Regular physical activity and a balanced diet to
support mental health.
◻ Stress Management: Meditation, mindfulness, journaling, or
relaxation techniques.
6. Monitoring & Follow-Up
◻ Follow-up in 1-2 weeks to assess medication response and
mood stability.
◻ Regular psychiatric appointments for long-term mood stabilization.
◻ Lab Monitoring (if on lithium or valproate):
Lithium levels (every 4-6 weeks initially).
Liver function tests & CBC (if on valproate).
Kidney function tests (for lithium).
Summary of Plan:
1◻⃣ Start mood stabilizer (Lithium or Valproate) & monitor
response.
2◻⃣ Psychotherapy (CBT/DBT) for mood and impulse control.
3◻⃣ Reduce alcohol use with counseling and support groups.
4◻⃣ Encourage lifestyle changes (sleep, exercise, stress management).
5◻⃣ Regular follow-ups & lab monitoring for medication safety.
