Psychotic Symptoms Nurse Case Study

You are meeting with Julia Marie Groffin, an 83-year-old woman whose wife brought her to the ER because she has been agitated, with an irritable mood, and mood-congruent  that started two weeks ago.

Chief Complaint: “My mood is fantastic!” Per her wife, “She’s been a different person. She’s been so agitated and irritable; she’s not sleeping; and she’s talking so much it’s hard to keep up with her. This started two weeks ago.”

History of Present Illness

Julia Marie has a long history of neuropathic pain that has been managed with Neurontin for several years. She was diagnosed with restless leg syndrome 1 month ago, and her neurologist started her on Ropinirole 1 mg daily and was titrated up to 3 mg daily within a 1-week span. Two weeks after starting this medication regimen, her wife reports that she noticed a change in her behavior including severe agitation, irritability, delusions of grandeur, decreased need for sleep, and racing thoughts.

Julia Marie states, “I’m a psychologist and the Missouri state boxing champion. I’m sure you’ve seen me in the papers. I decided that I’m running for Congress this next election cycle. It’s time we made some changes on Capitol Hill, and I’m just the woman for the job.” She reports she knocked on her neighbor’s door and propositioned them to buy their house while she was convincing them to vote for her in her campaign for Congress.

History

No prior psychiatric history or psychiatric treatment

Restless leg syndrome

Neuropathic pain

Social: committed relationship for 50 years, retired librarian, no history of alcohol or drug use

• Medications
• Neurontin (Gabapentin) 300 mg three times daily
• Ropinirole (Requip) 3 mg daily
• Physical exam is unremarkable.

Labs/Tests

CBC, CMP, UA, UDS, blood alcohol level, TSH, Vitamin B12, Folate—all within normal limits

CT Scan of head—no abnormalities

• Mental Status Exam
• She is easily agitated and uncooperative.

Her speech is fast—but not pressured—and has increased volume and tone.

Mood is labile with congruent affect.

Thought process is circumstantial with loose associations.

• Thought content includes flight of ideas and delusions of grandeur, no suicidal or homicidal ideation or perceptual disturbances.
• Insight: poor

Judgement: poor

Mini-mental status exam: 26/30, no evidence of cognitive impairment

• Questions
• From your perspective as Julia Marie’s psychiatric nurse practitioner, answer the following questions in a two- to three-page, double-spaced paper (not including the reference page) in APA format. Include at least three peer-reviewed, evidence-based references.
• What diagnosis or diagnoses best describe Julia Marie’s condition? Include the diagnostic criteria that are met and what criteria are not met for your selections.
• What is one rule-out diagnosis (medical or psychiatric) for Julia Marie?
• How would you manage Julia Marie’s condition? Indicate the name, dose, route, and frequency for the medication(s) you would start.
• Explain how your treatment plan would manage Julia Marie’s targeted symptoms.