Posted: May 15th, 2023

Topic: HPI: WG, a 31-year-old female

Topic: HPI: WG, a 31-year-old female, has been admitted to your inpatient unit from the ED where she presented unwillingly and accompanied by her husband. She is unable to provide a history right now, but her husband is able to give you the following information: He reports over the past 2 weeks the patient has been uncharacteristically energetic, starting tasks and not finishing them, exhibits hypersexuality, is highly distractible with a speech that is “nonsensical”. Her speech has also been rapid and pressured. She only sleeps every second or third night and has abdicated all attempts at self-care such as hygiene or grooming.

The ED diagnosed her with a manic episode.

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Substance Hx: There is no documented history of smoking, alcohol, or illicit substance use.

PPH: There is no history of any psychiatric illness in the patient or her family.

Labs: A full workup has been completed and all was normal with the exception of the abnormal findings listed in the table below:

Lab/Vitals

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Blood pressure: 150/90 (H)

Sodium :120 (L)
Include in your discussion:
What do you recommend for treatment (focus on psychopharmacologic treatment) and monitoring of WG’s current symptoms?
What, if any, considerations should be made?
Please be very specific in your answer and rationale. Do not go into detail about bipolar disorder at the expense of detail regarding the current treatment of the patient.
Choose your treatments as you would if the patient were in front of you.
Do not give vague or generalized treatment plans; choose a treatment and explain why you chose it instead of any other options.
Include all considerations that accompany your choice of the treatment plan. For instance, do any diagnostics need to be done prior to initiating a drug?

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Based on the information provided, WG is presenting with symptoms consistent with a manic episode, as diagnosed by the ED. Treatment for a manic episode typically involves a combination of pharmacotherapy and supportive interventions. Since the focus is on psychopharmacologic treatment, I will provide specific recommendations for medication and monitoring of WG's current symptoms.

Medication Recommendations:
Considering the symptoms described (elevated energy, hypersexuality, distractibility, nonsensical speech, decreased need for sleep, poor self-care), the most appropriate initial treatment for acute mania is the use of mood stabilizers, specifically lithium or an atypical antipsychotic.
a) Lithium: Lithium is a first-line treatment for acute mania. It has demonstrated efficacy in stabilizing mood and reducing manic symptoms. The recommended initial dose for acute mania is 900-1200 mg/day in divided doses. However, before initiating lithium, it is crucial to obtain a baseline serum lithium level and renal function tests (creatinine, estimated glomerular filtration rate) to ensure the patient is not at risk for lithium toxicity.

b) Atypical Antipsychotics: Another option for acute mania treatment is an atypical antipsychotic. Medications such as quetiapine, risperidone, or olanzapine are commonly used in this context. Quetiapine is often favored due to its efficacy and tolerability. The initial dose for quetiapine is 50-100 mg/day, with subsequent dose adjustments based on the patient's response. These medications should be titrated to the lowest effective dose to minimize side effects.

Monitoring of Symptoms:
Regular monitoring is crucial to assess the patient's response to treatment, ensure medication adherence, and identify any potential adverse effects. The following monitoring parameters should be considered:
a) Psychiatric Evaluation: Regular psychiatric evaluations should be conducted to assess the patient's symptom severity, treatment response, and overall well-being. These evaluations can help guide adjustments in medication dosages or treatment plans.

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b) Vital Signs: Blood pressure should be monitored regularly to evaluate for any changes or potential side effects associated with the chosen medications.

c) Laboratory Tests: Regular monitoring of serum lithium levels is essential for patients on lithium therapy. Initially, levels should be checked twice per week, and once the desired therapeutic range is achieved (0.6-1.2 mEq/L), monitoring can be reduced to every 1-3 months. Renal function tests should also be periodically checked in patients receiving lithium.

d) Side Effect Assessment: Assessing for medication side effects is crucial. Common side effects of lithium include tremor, polyuria, polydipsia, weight gain, and thyroid dysfunction. Atypical antipsychotics may be associated with metabolic side effects such as weight gain, dyslipidemia, and glucose intolerance. Monitoring for these side effects should be incorporated into the patient's care plan.

Considerations:
It is important to obtain informed consent from the patient or her legal representative before initiating any treatment. Given the patient's inability to provide a history at present, efforts should be made to involve her in the decision-making process once her capacity to provide consent is restored.
Additionally, it is essential to assess for any contraindications, allergies, or potential drug interactions before initiating any psychopharmacologic treatment. Reviewing the patient's medical history, current medications, and conducting a thorough physical examination can help identify any potential concerns.

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Lastly, involving the patient's husband and providing him with education and support can help improve medication adherence and contribute to the overall management of the patient's symptoms.

Please note that the recommendations provided are based on the limited information provided in the scenario. It is crucial to individualize the treatment plan based on the patient's

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