CASE LEARNING OBJECTIVES
Recognize the signs and symptoms of an acute manic episode and bipolar disorder
Identify the goals of therapy for an acute manic episode and bipolar disorder
Develop an appropriate treatment and monitoring plan for the pharmacotherapy of bipolar disorder using a specific patient presentation
Educate a patient on taking medications for bipolar disorder
"My mind's going too fast."
History of Present Illness
Lisa Walking is a 34-year-old woman who has been admitted to a psychiatric hospital. She was brought to the hospital by her husband after she stopped sleeping, would stay up all night praying, could not be redirected, and would say simply, "I am communicating with God." The husband reports LW had become more agitated during the past week with rapid speech, irritability, and now bizarre ideas about special powers and abilities. He indicates that "she explodes, anything sets her off, she was talking to people who are not there and has been hitting herself." She has poor insight into why she was brought to the hospital, but states, "I have problems with nerves and I don't sleep." She is seen on team rounds by a psychiatrist, nurse, pharmacist, psychologist, and social worker.
LW had all of the usual childhood illnesses.
She has a history of psychiatric illness with four hospitalizations dating to 1990, but this is the first admission to this hospital and none of the previous records are immediately available. She is followed on an outpatient basis at a community mental health center.
She has a history of HTN. The husband reports that the patient had "low blood" on her previous medication and this was one reason she stopped taking it.
Father healthy, except HTN, well controlled on medication. Mother has depression, takes paroxetine. She has three siblings, two brothers and one sister. One brother is alcoholic. She has no children.
Married, lives with husband. Unemployed; worked previously as a checkout clerk at a supermarket, but has not worked in over a year. High school graduate, but has difficulty with reading and writing. Receives supplemental security income payments and supported by husband. Receives Medicaid coverage. No pending legal problems. No special diet. No regular exercise program.
Occasional binge-drinking episodes. Smokes 1 ppd with approximately 20 pack-year history. Denies illicit substances. Drinks several cups of caffeinated coffee daily.
Allergies/Intolerances/Adverse Drug Events
Diazepam (nausea and vomiting after injection) during a previous hospitalization.
Paroxetine 20 mg PO daily × 3 months, started during previous hospitalization