| Course | NR 668 Psychiatric-Mental Health Capstone Practicum & Intensive |
|---|---|
| Week | 2 |
| Paper type | Case conference write-up |
| Length | About 1,100 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Psychiatric-Mental Health Nurse Practitioner (PMHNP) |
| Updated | October 2026 |
Free sample paper for NR 668 Week 2
Case Conference Write-Up: Bipolar II Disorder Found Behind a Referral for Treatment-Resistant Depression, Presented in Eight Minutes
Student Name
College of Nursing, Chamberlain University
NR 668: Psychiatric-Mental Health Capstone Practicum & Intensive
Instructor Name
Month Day, Year
Case Conference Write-Up: Bipolar II Disorder Found Behind a Referral for Treatment-Resistant Depression, Presented in Eight Minutes
Orientation
A 34-year-old graphic designer, referred by primary care for depression unresponsive to two SSRIs. I am bringing the case because collateral from the patient's partner changed the diagnosis to bipolar II disorder, and I want the group's view on the medication plan.
History, in the Order It Happened
At about 24, the patient had a first depressive episode during college, untreated, lasting several months.
Between 29 and 33, according to the partner, at least three stretches of four to five days with markedly less sleep, high energy, rapid speech, many projects started and two episodes of overspending. None led to hospitalization or loss of work. The patient did not regard these as illness; they called them "my good weeks."
At 33, a second depressive episode began after a job change: low mood, loss of interest, fatigue, poor concentration, guilt and passive thoughts of death. Their primary care clinician started sertraline, increased it to 150 mg over three months with little change, then switched to escitalopram, now at 20 mg for five months.
In the two weeks before the visit, sleep fell to about four hours, with a driven, irritable energy alongside persistent low mood, two large purchases and arguments at work.
Alcohol: two or three drinks most evenings, more during low periods. Cannabis occasionally for sleep. No other substances.
Family: a parent with "mood swings," never diagnosed; a maternal uncle who died by suicide.
Medical: no thyroid disease; body mass index 31; a parent with type 2 diabetes.
Social: lives with partner and their 6-year-old child; working full time; no firearms in the home.
Findings a Listener Could Check
Appearance: dressed casually, hair uncombed. Behavior: restless, shifting in the chair, tapping a foot through most of the interview. Speech: slightly rapid, normal volume, interruptible. Mood, in the patient's words: "exhausted but I can't stop." Affect: dysphoric, with brief irritable flashes when describing work. Thought process: goal-directed, with some tangents that returned to the question. Thought content: guilt about the family; passive wish not to wake up, no plan, no intent; no delusions. Perception: denies hallucinations, none observed. Cognition: oriented; three-word recall complete after five minutes. Insight: partial; accepted that the "good weeks" might be part of the same illness after the partner described them. Judgment: intact for the interview.
PHQ-9: 19. Mood Disorder Questionnaire: positive, with seven symptom items endorsed, clustering in the same period and moderate problems. Columbia suicide screen: passive ideation in the past month, no method, intent or plan, no lifetime attempts.
Laboratory results from primary care two weeks earlier: thyroid function normal, complete blood count normal, A1C 5.8%, fasting lipids mildly raised.
What Was Not Found
No psychotic symptoms now or in the past. No hospitalizations. No history of head injury or seizures. No prior self-harm. No legal problems. No current stimulant use, which matters because stimulants can mimic hypomania. These negatives are reported because each would have changed the formulation. A history of psychosis would have pointed toward bipolar I disorder; stimulant use would have offered another explanation for the recent activation; prior self-harm would have raised the risk assessment.
Formulation
Bipolar II disorder, current episode depressed, with mixed features in the past two weeks, likely worsened by antidepressant monotherapy. Contributing: alcohol use that may be both self-treatment and a destabilizer, job stress and a family history of mood disorder and suicide. The diagnosis rests on the partner's account of hypomanic episodes lasting at least four days, which the patient had not recognized as illness. The screening questionnaire supports but does not make the diagnosis (Hirschfeld et al., 2000).
Plan, With Numbers
Taper escitalopram from 20 mg to 10 mg for one week, then stop, because antidepressant monotherapy is not recommended in bipolar depression with mixed features, and adjunctive antidepressants did not add benefit in a large trial (Sachs et al., 2007).
Start quetiapine 50 mg at bedtime, increasing to 100 mg on day 2, 200 mg on day 3 and 300 mg on day 4, the dose used in bipolar depression trials, with guideline support as first-line for bipolar II depression (Yatham et al., 2018).
Baseline weight, waist circumference and blood pressure taken today; fasting glucose and lipids to be repeated at 12 weeks.
Safety plan completed in the visit, with the partner present, and the 988 crisis line number written on it (Stanley & Brown, 2012).
Alcohol: advised to stop during the medication change, with a plan to revisit at the next visit.
Review in two weeks, sooner by phone if sleep does not improve within five days or if thoughts of death increase.
Coordination
A letter to the primary care clinician went the same day, explaining the change in diagnosis, the taper and the new medication, and asking them not to restart an antidepressant without discussion. Primary care is also where metabolic monitoring would most naturally continue, so the letter asked for weight and blood pressure at their next visit.
What I Would Like the Group to Notice
That the history the patient gave alone did not support the diagnosis. Only with the partner's account did the episodes appear. The screening questionnaire, completed after the partner spoke, came back positive; completed before, it might not have. Mood disorders are often missed in primary care when hypomania is not recognized by the patient as illness (Angst et al., 2011), and asking someone who lives with the patient is the cheapest way to find it.
Time Course of the Plan
Days 1 to 4: quetiapine titration; escitalopram 10 mg. Day 5: telephone check on sleep and mood. Day 8: escitalopram stopped. Week 2: visit with PHQ-9, Columbia screen, weight and a review of sedation at work. Week 6: fasting glucose and lipids. Week 12: decision on maintenance treatment. Each point has a measure attached, so that whoever sees the patient next can judge progress without rereading the whole note. Measuring the PHQ-9 at each visit gives a consistent way to judge change (Kroenke et al., 2001).
Question for the Group
Would you have chosen lamotrigine instead, given the metabolic risk, accepting the six-week titration while the patient remains depressed? And would anyone have kept the escitalopram, on the grounds that it had helped a little at first? Arguments either way would help before the patient's week 2 visit.
References
Angst, J., Azorin, J.-M., Bowden, C. L., Perugi, G., Vieta, E., Gamma, A., & Young, A. H. (2011). Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: The BRIDGE study. Archives of General Psychiatry, 68(8), 791-798. https://doi.org/10.1001/archgenpsychiatry.2011.87
Hirschfeld, R. M. A., Williams, J. B. W., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Jr., Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry, 157(11), 1873-1875. https://doi.org/10.1176/appi.ajp.157.11.1873
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Sachs, G. S., Nierenberg, A. A., Calabrese, J. R., Marangell, L. B., Wisniewski, S. R., Gyulai, L., Friedman, E. S., Bowden, C. L., Fossey, M. D., Ostacher, M. J., Ketter, T. A., Patel, J., Hauser, P., Rapport, D., Martinez, J. M., Allen, M. H., Miklowitz, D. J., Otto, M. W., Dennehy, E. B., & Thase, M. E. (2007). Effectiveness of adjunctive antidepressant treatment for bipolar depression. New England Journal of Medicine, 356(17), 1711-1722. https://doi.org/10.1056/NEJMoa064135
Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264. https://doi.org/10.1016/j.cbpra.2011.01.001
Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., Sharma, V., Goldstein, B. I., Rej, S., Beaulieu, S., Alda, M., MacQueen, G., Milev, R. V., Ravindran, A., O'Donovan, C., McIntosh, D., Lam, R. W., Vazquez, G., Kapczinski, F., . . . Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97-170. https://doi.org/10.1111/bdi.12609
The Chamberlain NR 668 Week 2 instructions
Write it to be spoken in about eight minutes. Open with a one-line identification and the reason you are bringing the case. Give the history in the order it happened, not the order the record holds it, so listeners can see the pattern. Report findings as observations someone could check: what the patient did and said, not adjectives about them. Include relevant negatives, since each one rules something out. Keep the formulation short and take a position. State the plan with numbers: what was started, at what dose, with what review point and what monitoring. Add coordination with other clinicians. End with a specific question you want the group to answer, so the conference does work for the patient.
Inside the NR 668 Week 2 example
The sample identifies a 34-year-old referred after two SSRIs and asks the group about the medication plan. History runs from an untreated episode at 24 through partner-described hypomanic stretches from 29 to 33, a second depression at 33, sertraline and escitalopram trials and two weeks of mixed symptoms. Alcohol, family history of suicide and metabolic risk are included. The mental status examination describes restlessness, rapid but interruptible speech and passive ideation without plan. Relevant negatives rule out psychosis and stimulant use. The formulation commits to bipolar II depression with mixed features. The plan tapers escitalopram, titrates quetiapine, sets monitoring and a day-by-day time course and writes to primary care. Its closing question asks the group whether lamotrigine or keeping escitalopram would have been better.
Where the points sit in the NR 668 Week 2 rubric
Case conference write-ups lose most when they follow the record's order, scattering the history so the pattern is lost. Next are findings written as adjectives, such as anxious or labile, which no listener could check. Many write-ups leave out relevant negatives, so listeners cannot tell which alternatives were considered. Formulations that list possibilities without committing give the group nothing to challenge. Plans without doses, review points or monitoring cannot be judged. Write-ups that run far beyond eight minutes when read aloud miss the format. Ending without a question for the group wastes the conference, since the point is to get colleagues' judgment on something still open. Write-ups that skip coordination with primary care also leave the antidepressant liable to be restarted elsewhere.
NR 668 Week 2 help from the desk
Turning a full evaluation into eight spoken minutes means cutting most of it while keeping the pattern visible. A guided draft can help you order the history as it happened, rewrite findings as observations and add the negatives that matter. We can also help you write a formulation that commits and a plan with doses and review points. Reading the draft aloud against a timer is usually the quickest way to find what to cut. The case and the plan are yours. We can also help you choose the one question to put to the group.
Get a NR 668 Week 2 example written to your instructions
Send the Week 2 instructions and the rubric, along with the format your section wants, whether that is a paper, a script or slides with notes, and a custom example is written to it and returned inside 24 to 48 hours. The first one is free. The patient and the decisions remain yours to supply.
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NR 668 Week 2 questions, answered
How long should a case conference write-up be?
Whatever your section sets, though the useful test is time rather than word count. If the written version cannot be delivered aloud inside the slot your classroom names, it is carrying material that a listener would not have kept anyway. Writers who read the draft out with a clock running usually cut a third of it without losing anything a colleague needed.
Does the formulation repeat the history?
It should not, and this is the most common structural fault in the assignment. History says what happened; formulation says why, in terms somebody could argue with. If a reader can delete the formulation and lose no information, it was a summary. Naming the competing explanation you rejected, in one clause, usually converts it into the paragraph the rubric was asking for.
Should the write-up include what I would do differently?
Only if the instructions ask, and even then keep it to a line or two. A conference document exists to let colleagues act on a patient, not to display insight. Where a section does want it, the honest version names a specific decision and the point at which better information was available, rather than a general statement about learning from the case.
Where can I find a free NR 668 Week 2 sample paper?
This page holds the full case conference write-up on bipolar II disorder found behind a depression referral.
Why does the NR 668 Week 2 plan stop the escitalopram?
Antidepressants are not recommended in bipolar depression with mixed features, and adding them did not improve recovery in a large trial.