Follow-up for a 33-year-old male post discharge from inpatient psychiatric stay

Patient Name: XXX
MRN: XXX
Date of Service: 02-13-2020
Start Time: 09:00
End Time: 10:49
Billing Code(s): 90853, 90791
Accompanied by: Mother
CC: Follow-up for a 33-year-old male post discharge from inpatient psychiatric stay
HPI: The patient was admitted to an inpatient facility two weeks ago due to mental health issues, following several weeks of uncontrolled mania and irritability. His admission followed an episode of violent aggression against his mother. Initially presenting with a depressed mood, agitation, and confusion about the events leading up to his admission, he has been receiving regular inpatient psychiatric sessions and taking Depakote 500mg. He was discharged three days ago.
S: The patient reports significant improvement since his discharge. He feels more in control, his mood is stable, and his irritability has decreased. He denies any suicidal or homicidal ideation. He has been compliant with his medication and has not experienced any side effects. He reports improved sleep and regular exercise.
Crisis Issues: The patient denies any active crisis issues.
Reviewed Allergies: None known allergies
Current Medications: Depakote 500mg Daily
ROS:
Constitutional: Patient reports feeling better and more in control since discharge from inpatient psychiatric care.
Eyes: No vision changes or vertigo reported.
ENT: No hearing difficulties or ear pain reported.
Cardiovascular: No chest discomfort reported.
Respiratory: No cough reported.
GI: No constipation or stomach discomfort reported.
GU: Asymptomatic.
Musculoskeletal: No stiffness or arthralgias reported.
Skin: No lesions reported.
Neurologic: No numbness, tremors, or proximal muscle weakness reported.
Endocrine: No heat or cold intolerance, weight gain or loss, excessive thirst or urination, or excessive sweating reported.
Hematologic: No easy bruising or bleeding reported.
O:
Vitals: T 97.4, P 82, R 14, BP 120/72
PE: The patient presents as a 33-year-old white male, dressed casually and with good grooming. His mood is neutral and his affect is appropriate to the conversation. He appears cognizant of his surroundings, is oriented x3, and maintains good eye contact. His speech is fluent, and his thought process is coherent. He denies any current suicidal or homicidal ideation, auditory or visual hallucinations, or delusions. His judgment, insight, and reliability appear intact, and he is able to provide informed consent.

A – with (ICD-10 code)
Differential Diagnoses:

Major Depressive Disorder – F32.9 (Abdoli et al., 2021)
Schizoaffective Disorder – F25.0 (Archibald, 2019)
Psychotic Disorder – F29 (Jongsma et al., 2019).
After considering the differential diagnoses, the patient’s clinical presentation aligns with bipolar disorder, current episode severe manic (F30.2, Carvalho et al., 2020). Bipolar disorder was chosen as the definitive diagnosis based on the DSM-5 criteria for mania, which includes an abnormal and persistently elevated, expansive, or irritable mood, along with specific symptoms such as grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, hyper-sexuality, and increased involvement in pleasurable activities with a high potential for painful consequences (Carvalho et al., 2020).

P:

Increase the daily dose of Depakote to 1000mg.
Continue outpatient counseling: Twice weekly psychotherapy sessions involving cognitive-behavioral therapy (CBT).

Non-pharmacological Treatment:

Exercise (Rosson et al., 2022).
Relaxation techniques.
Time management (Rosson et al., 2022).
Positive self-talk.
Increased social engagement (Rosson et al., 2022).
Psychoeducation about bipolar disorder.
Sleep hygiene (Rosson et al., 2022).
Stress management strategies.
Socialization activities (Rosson et al., 2022).
Mindfulness-based coping.
Pharmacological Treatment:

Depakote tablets 1000mg daily (Jongsma et al., 2019).
Lamotrigine 25mg daily.
Quetiapine 50mg twice daily (Jongsma et al., 2019).
Omega-3 supplements.
Fluoxetine 10mg daily (Jongsma et al., 2019).
Education:

Self-monitoring of mood and symptom fluctuations (Jongsma et al., 2019).
Differentiating between manic symptoms and behaviors.
Ways to manage stress and triggers of mania.
Balancing sleep, relaxation, and exercise (Jongsma et al., 2019).
Recognizing early warning signs of manic or depressive episodes.
Identifying and managing potential side effects of medication.
Achieving and maintaining proper nutrition.
Building and practicing coping mechanisms.
Disclosing symptoms to family, friends, employers, and healthcare professionals.
Managing family dynamics (Jongsma et al., 2019).
Identifying and utilizing additional support resources.
Engaging in open communication with healthcare providers (Jongsma et al., 2019).
Making reasoned decisions about medication changes.
Techniques to enhance medication adherence.
Proactive strategies to reduce the risk of relapse (Jongsma et al., 2019).
Follow-up: The patient will follow up in one week for medication management and will continue with the above-outlined interventions.

Referrals: The patient will be referred to a psychiatrist and a nutritionist.

References:
Abdoli, N., Salari, N., Darvishi, N., Jafarpour, S., Solaymani, M., Mohammadi, M., & Shohaimi, S. (2021). The global prevalence of major depressive disorder (MDD) among the elderly: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 132. https://doi.org/10.1016/j.neubiorev.2021.10.041
Archibald, L. (2019). Alcohol Use Disorder and Schizophrenia and Schizoaffective Disorders. Alcohol Research: Current Reviews, 40(1). https://doi.org/10.35946/arcr.v40.1.06
Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar Disorder. New England Journal of Medicine, 383(1), 58–66. https://doi.org/10.1056/nejmra1906193
Jongsma, H. E., Turner, C., Kirkbride, J. B., & Jones, P. B. (2019). International incidence of psychotic disorders, 2002–17: a systematic review and meta-analysis. The Lancet Public Health, 4(5), e229–e244. https://doi.org/10.1016/s2468-266