Transcript Case Presentation

CASE PRESENTATION
Student Name
Chief Complaint
 I am on papers and I need to
see a doctor
 Pennsylvania has me on
some crazy papers
History of Present Illness
 VH is a 31y/o unemployed African American
female who has been on disability aid since
2008 for her mental illness.
 Referral from PCP due to her history of bipolar
disorder, questionable schizophrenia, non
compliance with medication for over a year.
 Patient reports that she is “super super super
happy” and that she is liked by all her friends
due to her sense of humor
 She insists that she is normal and does not
need any medication
 Denies sleep disturbances but admits to
cursing people out a lot when frequently
irritated.
 Been hospitalized several times in the past
due to depression episodes, manic episodes
and suicidal attempts
HPI contd….
 First suicide attempt was in 1995
 Stabbed herself multiple times in
her forearm veins but claims it
was superficial
 Also tried to jump off a bridge on
one suicidal attempt
 She denies any symptoms of
depression
 Denies any current SI, PDW, HI
 Does not have access to firearms
Past Medical History
 Asthma
 Thrombocytopenia
 s/p hysterectomy
Family History
 Patient has 4 children (12,10,9 and 7
year olds)
 Mother still lives in PA. Medical
problems include HTN, arthritis
 Father died due to throat cancer (was
an alcoholic and drug addict)
 2 brothers and 2 sisters
 History of alcohol and substance
abuse in the family
 3 nephews have bipolar disorder
 History of anxiety disorders in the
family
Social History
 Moved to DC from Pennsylvania a
couple of months ago
 Currently lives with her boyfriend
whom she claims to have a good
relationship with
 Denies current tobacco, alcohol,
heroin, cocaine, marijuana use
 Last marijuana use was in October
2010
 Last alcohol use was in Jan 1 2010.
Before that, was drinking occasionally
Personal History
 Born and raised in PA
 Said she had a bad childhood. Felt
unwanted by her father and was
physically abused by her brother in-law
when she was 12 y/o
 Highest level of education was 11th grade.
Got pregnant and dropped out of school
 Divorced since 2008 married for 7 years
to an abusive husband who was
controlling and cheating on her
 Never enrolled in the military
 Longest job held was as a personal care
aid for about 3-4 months
 Never been arrested
Medications
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Aripiprazole (Abilify)10mg
Risperidone (Risperidal)
Quetiapine (Seroquel)
Citalopram (Celexa)
P.S : Medications were last taken about
1-5 years ago
Allergies
 No known drug allergies
Mental Status Exam
 Appearance/Behavior: middle aged well
dressed and well groomed female. Slightly
obese with a tongue ring. Maintained direct
and good eye contact through out the
interview
 Speech: Clear, coherent with rapid speech and
increased tone
 Mood/Affect: Patient says she is a “super
super super happy mood”. Affect is labile and
irritable.
 Thought Process: Linear, organized and goal
directed
 Thought Content: Denies SI, HI, delusions
 Perception: Denies AH/VH/TH
 Cognition: Alert and oriented X3
 Insight/Judgment: Poor judgment and insight
Differential
diagnosis?
Multi-axial Formulation
 Axis I: BPAD II
 Axis II: Borderline
Personality disorder
 Axis III: Thrombocytopenia,
asthma, s/p hysterectomy
 Axis IV: Poor social support,
poor coping skills
 Axis V: 55-60
Biopsychosocial
Formulation
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Ms. VH is a 31 year old African American female
who is the mother of 4 children, unemployed, on
disability aid and lives with her current boyfriend
She presented to the clinic on referral by her
Primary care Physician (Dr. Mary McDonald) who
wanted her evaluated due to her history of bipolar
disorder and her non-compliance with her
medications
Biologically, Ms. VH has a history of bipolar
disorder in her family (3 of her nephews).
Genetically, many studies have shown many
chromosomal regions appearing to relate to the
development of bipolar disorder even though most
of the results are not consistent when replicated
Most people start showing signs of bipolar disorder
in their late teens (the average age of onset is 21
years). These signs may be dismissed as "growing
pains” or normal teenage behavior.
Biopsychosocial
formulation
 On occasion, some people have their first
symptoms during childhood, but the
condition can often be misdiagnosed at this
age and improperly labeled as a behavioral
problem.
 Bipolar disorder occurs in both men and
women. About 5.7 million people in the
United States have the disorder. There is no
racial group that is more afflicted by this
disease.
 Psychologically, the patient appears to still be
holding on to some of the pain and rejection
she felt during her childhood
 Her history of abuse, also plays an important
role in her psychiatric history. This could
contribute to her low self esteem and
worthlessness
Biopsychosocial
formulation
 Patient seems to down play the effect her
childhood had on her. It is important to
explore here childhood and adolescent
relationships
 Socially, VH did not graduate from high
school and the longest job she held was for 4
months.
 She lives with her boyfriend who is also
unemployed and the two of them live of her
disability aid
 The patient also does not get along with her
family and has no primary family support
 However, patient seems to enjoy her
relationship with her current boyfriend
Treatment Plan
 Start patient on a mood stabilizer, Abilify
10mg qHS.
 Discuss possible adverse effects such as
metabolic syndrome, weight gain, tardive
dyskinesia, neuroleptic malignant syndrome,
extrapyramidal side effects, anti-histamic
(sedation), anti-alpha adrenergic(orthostatic
hypotention, cardiac abnormalities), antimuscarinic (dry mouth, tachycardia, urinary
retention, constipation, blurry vision)
 Obtain baseline basic blood work which
includes CMP, lipid panel, TSH, fasting glucose
 Psychotherapy including CBT, interpersonal
therapy, psychodynamic therapy (IT,GT,FT)
 Appointment with social worker
 Follow up appointment in one month