Category: Diagnosis - Beyond The Body

Beyond The Body

Think Like A Psychiatrist - Suicidal and Requesting Money

3/9/2017

Put your knowledge and skills to the test with Mr. L who presents himself to hospital following an intentional overdose with acetaminophen. Upon psychiatric assessment, the patient reports that he is depressed, but his mood and suicidal ideation are directly related to his current financial situation as he is worried he cannot afford food or his medical expenses.

The patient has a history of a developmental disability, and describes a lack of social support, despite nearby family. He tells you that the hospital could help provide him food and requests $600 to alleviate his financial stressors and suicidal thoughts.

He is noted to have been last admitted 3 weeks ago, and has since visited the ER on 2 previous occasions requesting food, money, and residential facility placement.

What is your differential diagnosis? How would you manage this patient's requests?

"Suicidal and asking money for food" by Kuklinski LF, Davis MJ, and Folks DG (Current Psychiatry).

Think Like A Psychiatrist - A Child With Self-Injurious Behaviour

3/2/2017

Put your knowledge and skills to the test with the case of patient A, a 6 year old child, who is brought to your office due to a repetitive self-injurious behaviour in which she repeatedly jams her finger into her nose, leading to multiple nosebleeds per day.

Based on additional history, you determine that these symptoms began at age 3, and are associated with multiple fears (vomiting, storms, public bathrooms, parents' dying), bedtime checking rituals, and involuntary motor and vocal tics such as facial grimacing and throat clearing. She has recurrent UTIs, but is otherwise healthy. There is no history of trauma/abuse. She has been receiving CBT for the last year, and is not on any meds.

What diagnoses are on your differential? What further information would help you distinguish between these diagnoses? What treatment would you suggest?

"A girl repeatedly jabs her finger up her nose: Compulsion or self-injury?" by Butkus M and Vinch J (Current Psychiatry).

Think Like A Psychiatrist - Psychotic Symptoms and A Previous Diagnosis of Neurosyphilis

8/24/2016

Put your knowledge and skills to the test with the case of Mr. C, a 61 year old man, who presents to clinic for follow-up on his antipsychotic medications that are used to manage psychosis and depression. He currently uses chlorpromazine 100mg/day and has had no psychotic symptoms in the last 3 years.

In terms of his psychiatric history, Mr. C first began to experience auditory and visual hallucinations at age 48, as well as a decline in cognition that led to his retirement from employment shortly thereafter. He has had 3 inpatient psychiatric admissions, and has continued to be treated with antipsychotics as discontinuation often leads to relapse of his psychosis.

While Mr. C has a history of aortic regurgitation, CHF, HTN, and sensorineural hearing loss, he also describes a history of cocaine abuse from 21-45. More interestingly, he also reveals a diagnosis of syphilis at 48yo, which went untreated for many months until he was diagnosed with neurosyphilis (tertiary syphilis) after developing abnormal gait, blurred vision, and general weakness.

Do you think Mr. C's psychiatric symptoms are related to his diagnosis of neurosyphilis? What tests would you order? What would you advise him on further management/treatment?

"Psychosis in Treated Neurosyphilis: Is Now The Time To Stop His Antipsychotic?" by Kamalika Roy, Richard Balon, and Varma Penumetcha.

Think Like A Psychiatrist - On A Mood Stabilizer, But Develops Odd Gait, Incontinence and Cognitive Impairment

8/3/2016

Put your knowledge and skills to the test with the case of Mr. X, a 67yo male, who presents with new-onset cognitive impairment, gait disturbance, dyskinesia, and urinary incontinence of 2 months duration. Mr. X now requires assistance with most ADLs including ambulation.

In terms of psychiatric history, he was diagnosed with ‪‎bipolar‬‪ ‎depression‬ 8 years ago, and has since been effectively treated with ‪valproic acid‬ and venlafaxine. Serum valproic acid level is within the therapeutic range.

What work-up would you order? What diagnosis or differential diagnosis are you considering?

"Treated with a mood stabilizer, he becomes incontinent and walks oddly" by Kumari S, Sridhar R, and Rao M (Current Psychiatry).

Think Like A Psychiatrist - Depressed and Suicidal Following Loss of a Baby, But No Evidence of Pregnancy

7/13/2016

Put your knowledge and skills to the test with the case of Ms. R, a 50 year old woman who was brought to the hospital by police after her sister reported that she was "very depressed" and wanted to take an overdose of medications to end her life because her newborn baby died 1 week before from SIDS.

Ms. R had provided her adult son and sister with a sonogram picture of her baby, as well as an obituary for the child, however both pictures were identified as having been forged and of other children obtained on the internet. In addition, Ms. R had a negative BHCG test, and medical records demonstrate no recent pregnancy but rather a history of hysterectomy 10 years earlier.

With regards to her psychiatric symptoms and history, Ms. R describes many symptoms of ‪‎depression‬ including low mood, anhedonia, guilt, decreased energy, poor sleep and concentration and suicidal ideation. She also reports a history in the past of ‪‎manic‬ episodes, as well as a previous ‪suicide‬ attempt, and a history of physical abuse.

What is your ‪‎diagnosis‬ for this patient? What treatment would you recommend?

"No evidence of pregnancy, but she is suicidal and depressed after 'my baby died'" by Pierce A, Turner A, Gilbo N, Ginory A, Korah T, and Tandon R. (Current Psychiatry)

Think Like A Psychiatrist - Manic After A Cruise

4/7/2016

Put your knowledge and skills to the test with the case of Mr. K, a 36 year old male, who presents to the ER with his wife, with new symptoms of elevated mood and self-esteem, decreased sleep, increased speech, racing thoughts, distractibility and increased goal-directed activity. They report that these symptoms began 10 days ago after they returned home from a cruise vacation.

Mr. K has no past psychiatric medication or recent substance use. His family history is significant for a brother who had a single manic episode and past suicide attempt in his adolescence. Mr. K is employed at a biotechnology company, where he does shiftwork, however since returning from his cruise, he has been unable to go to work due to his current symptoms.

Mr. K does not take any regular medications however, he reports using scopolamine for motion sickness on the cruise, and his wife tells you that she believes this may have led to his developing mania.

What would you say to Mr. K and his wife? What is Mr. K's diagnosis? How would you treat his manic symptoms?

"Manic After Taking A Vacation" by Embay Tan (Current Psychiatry).

Think Like A Psychiatrist - Catatonia After Using 'Spice'

3/11/2016

Put your knowledge and skills to the test with the case of Mr. R, a 19 year old, who presented to the ER with mutism, reduced oral intake, and ‪catatonia‬. His family tell you that these symptoms gradually developed over the last month after Mr. R began using a synthetic cannabinoid called "Spice".

Mr. R has no past psychiatric history, although there have been new psychosocial stressors in his life recently. Mr. R has used marijuana in the past and experienced paranoia while using this substance.

What investigations would you order? How would you treat this patient?

"Unresponsive and mute after he smokes 'Spice'" by David R Williams, Brian J Miles, Aniket Tatugade, Ranjan Avasthi, and Peter F Buckley (Current Psychiatry).

Think Like A Psychiatrist - A Case of Malignant Catatonia

12/3/2015

Put your knowledge and skills to the test with the case of Mrs. M, a 37 year old woman, who two weeks after an admission to hospital following an overdose where she received treatment for rhabdomyolysis and multi-organ system failure, returns to hospital and is diagnosed with ‪‎catatonia‬. During her admission, she develops fever, tachycardia, and increased rigidity and is presumed to have malignant catatonia. She undergoes multiple courses of ‪ECT‬ and clinically improves, but is noted to have persistent word-finding difficulties.

Her medical and psychiatric history includes type 2 diabetes, ‪#bipolar‬ disorder, and opioid, ‪‎cocaine‬, and ‪‎alcohol‬ use disorders. Her medications include gabapentin and paroxetine.

What is your differential diagnosis? What work-up would you order for this patient?

"Malignant catatonia and aphasia follow multiple drug overdose" by Neeta Shenai, Crystal White, Pierre Azzam, Priya Gopalan, and LalithKumar K. Solai (Current Psychiatry).

Think Like A Psychiatrist - A Case of Drug Use and Psychosis

11/4/2015

Put your knowledge and skills to the test with the case of Mr. D, a 23 year old male, who presents with new-onset ‪psychosis‬ with auditory and visual ‪hallucinations‬ and ‪catatonia‬ 10 days after taking 2C-B, a new designer drug. Specifically, Mr. D reported that he and his friends obtained 2C-B off the internet, and while his friends recovered well after using the drug, Mr. D instead has been decompensating. He reported abruptly quitting his job and thinking he is in alien in a spaceship over the last few days.

While his family and friends report that Mr. D has been acting strange, sleeping only 2-3 hours a night and talking rapidly since the use of the drug, they deny any other recent stressors in his life. They report that Mr. D is an Ivy-League educated man and has no significant medical or psychiatric history, and no family history of psychiatric disorders. About 1 month ago however, Mr. D began to smoke marijuana daily.

What is your differential for this patient? What work-up would you order? How would you treat his psychosis and catatonia?

"Psychosis and catatonia after dancing with a dangerous partner" by Surbhi Khanna, Jordan Rosen, Derek Blevins, and Pamila Herrington (Current Psychiatry)

Think Like A Psychiatrist - Homeless, Malnourished and Disorganized

10/8/2015

Put your knowledge and skills to the test with the case of Mr. N, a 48 year old gentleman, who has a longstanding psychiatric history involving multiple admissions to hospital for bipolar disorder, and ‪‎schizophrenia‬. He has been tried on numerous medications, however he is often non-compliant with treatment, which results in delusions and disorganized thoughts. He has been ‪‎homeless‬ for much of his life, has cellulitis of both legs and chronic venous stasis, and has obsessive-compulsive and paranoid personality traits.

Most recently, Mr. N was arrested for possession of ‪#cocaine‬, and was placed in jail where his mental status deteriorated further. He was declared incompetent to stand trial and was transferred to a psychiatric facility. He denies any suicidal or homicidal ideation, and fails to show signs of perceptual disturbances, however he does have poor insight and judgment.

What work-up do you think Mr. N requires to investigate his deteriorating mental status? What's on your differential and how would you manage this case?

"Malnourished and psychotic, and found incompetent to stand trial" by Patel R.R, Hornstra R, Munro S, and Dellenbaugh T (Current Psychiatry).