Category: Diagnosis - Beyond The Body

Beyond The Body

Think Like A Psychiatrist - A Case of Lip Smacking & Tongue Rolling

9/3/2015

Put your knowledge and skills to the test with the case of Ms. X, a 65 year old woman, with a long-standing history of ‪bipolar disorder "characterized by psychotic mania and severe suicidal depression." Ms. X's symptoms have been well managed with a combination of aripiprazole, trazodone and citalopram. However, due to change in her insurance coverage, Ms. X learns that aripiprazole will no longer be covered and so she requests a different medication. She is subsequently switched to quetiapine.

At her follow-up visit a few weeks later, Ms. X is noted to have a euphoric mood, decreased sleep, flight of ideas, and paranoia. She is also observed by her psychiatrist to be smacking her lips and rolling her tongue quite frequently.

What is the cause of Ms. X's involuntary movements? How would you manage this patient?

"A medication change, then involuntary lip smacking and tongue rolling" by Apeksha Shah, Shivam Dubey and Piyush Das (Current Psychiatry)

Think Like A Psychiatrist - A Teen who is Depressed and Won't Eat

8/6/2015

Put your knowledge and skills to the test with this case of Miss A, a 13 year old girl who is admitted to a pediatric unit after an episode of syncope and LOC that was preceded by prodromal symptoms. During an initial assessment, the patient reports significant preoccupation with weight gain and tells you that she has been restricting her calories and engaging in purging behaviours including vomiting, laxative use, and excessive exercise. She had stopped eating and drinking 3 days prior to her presentation to hospital. While demonstrating multiple depressive symptoms, her MSE most notably shows considerable psychomotor retardation, a blunted affect, poverty of speech, and delayed responses.

Miss A has no personal history of mental illness, but does endorse passive suicidal ideation and self-injurious behaviour recently. There is also family history of both bipolar disorder and anorexia nervosa.

How would you work this patient up? Can you come up with a diagnosis or treatment plan?

"A depressed adolescent who won’t eat and reacts slowly" by Shephali Sharma and Julie Alonso-Katzowitz (Current Psychiatry)

Think Like A Psychiatrist - Dizzy, Confused and a History of Depression

7/2/2015

Put your knowledge and skills to the test with this case of Mr. M, a 73 year old man, who presents to the ED after becoming light-headed and dizzy while walking his dog, in the context of worsening memory loss and increased syncopal events/hypotension over the last year. With regards to Mr. M's psychiatric history, he has experienced multiple episodes of depression‬ beginning 15 years ago, for which he has been treated with a variety of antidepressants. His medical history is also quite complex and is significant for hypertension, CAD, triple bypass surgery, hyperlipidemia, and erectile dysfunction.

Can you come up with a diagnosis or treatment plan?

"Depressed and confused,and dizzy while walking the dog" by Adriana Sofia Perilla, Rekha Bandla, and Murali Rao (Current Psychiatry)

Think Like A Psychiatrist - A Physician With Depression & Pain

6/4/2015

Put your knowledge and skills to the test with this case of Dr. D, a 33 year old physician who presents with depression, suicidal ideation, and somatic complaints. He tells you about the many pressures of running his practice, including financial stresses, of conflicts with his wife, of feeling lonely and having a lack of close friends, and of feeling generally unhappy, unsatisfied and exhausted. On top of his emotional complaints, he also describes increased tension and pain from his shoulders, neck and face. He has also noticed that he has not been as attentive, which has begun to impact his work performance and patient care. With regards to family history, both Dr. D's mother and grandfather had depression.

How would you manage this patient? What treatment would you offer or suggest?

"A physician who feels hopeless and worthless and complains of pain" by Daniel J. Rapport, Angele McGrady, Vipul Mahajan, and Ernest Brookfield (Current Psychiatry).

Think Like A Psychiatrist - Alcohol Abuse and Altered Mental Status

5/7/2015

Put your knowledge and skills to the test with a case of a 26 year old man who presents to the ED with intermittent confusion, weakness, lethargy, abdominal pain and jaundice. With regards to his past medical and psychiatric history, the patient has an alcohol use disorder, and drinks up to 1L of vodka a day. He was recently hospitalized 6 months ago for alcoholic hepatitis and severe hyponatremia. Blood alcohol and urine drug screens are negative, and a head CT is done to rule out an acute intracranial pathology.

What is causing this patient's symptoms? How would you manage this patient?

"Sober Today, But Lethargic and Confused" by Kathryn Faloba, Viwek S. Bisen, Anthony M. Tobia, Adam J. Trenton, and Aphrodite M. Zimmerman (Current Psychiatry)

Think Like A Psychiatrist - Depressed and Requesting Withdrawal of Treatment

4/9/2015

Put your knowledge and skills to the test with a case of a 76 year old man, who was admitted to hospital after a fall and reports feeling depressed and tired, and wants all life sustaining therapies withdrawn and tells his family and healthcare team that he "has had enough, i'm done" and to "just let me go".

The patient's medical history includes hypertension, diabetes and CAD. While in hospital for the fall he developed pneumonia that led to respiratory failure and the need for a tracheostomy. He then developed c difficile colitis and ARF that required temporary renal replacement therapy. During his hospital stay he was transferred to the ICU multiple times, once for management of ileus where he required an NG tube, a second time for management of a pneumothorax, and the third time for bronchoscopy and ventilation.

In terms of mental health history, he reports a 30 year history of depression managed with trials of medications, psychotherapy and even ECT.

How would you assess this patient's capacity to make treatment decisions? How would you manage this patient?

"Depressed and sick with ‘nothing to live for’" by Alyson Kepple, Priya Gopalan, and Pierre N. Azzam (Current Psychiatry)

Think Like A Psychiatrist - A Case of Malingering?

3/13/2015

Put your knowledge and skills to the test with a case of a 32 year old man, who pleads not guilty to rape charges by reason of insanity. The patient is assessed by a forensic‬ psychiatrist and reports that since suffering a head injury a number of years ago, he has experienced personality changes, psychosis‬, and violent behaviour. The patient argues that his actions were beyond his control, and that due to his brain injury he suffered from hallucinations and aggressive behaviour.

Is this a case of malingering‬?

"Did brain trauma lead to crime?" by Helen M. Farrell and Henry A. Nasrallah (Current Psychiatry)

Think Like A Psychiatrist - Aggressive & Delusional

2/5/2015

Put your knowledge and skills to the test with the case of an 78 year old man who presents to hospital as for the last few weeks he has been both verbally and physically aggressive toward his wife, and has been ruminating about his father who died in the war. There has also been a noticeable decline in the patient's function as he has not been bathing, eating, taking his medications, or sleeping for more than 1-2 hours a night. He experiences flight of ideas and irritability, and has been buying lottery tickets and telling his family he will become a millionaire. He also has paranoid delusions about others trying to hurt him.

He has no past psychiatric history, nor any history of substance abuse, and endorses only having a depressed mood. He does however have a complex medical history for which he takes many medications for, including diabetes, hypertension, dyslipidemia, and a recent CABG.

Can you come up with a diagnosis or treatment plan?

"Delusional and Aggressive While Playing the Lottery" by Muhammed Rehan Puri and Suhey Franco (Current Psychiatry)

Think Like A Psychiatrist - Visual Hallucinations in the Elderly

1/15/2015

Put your knowledge and skills to the test with the case of an 82 year old woman who presents to the ED as she has become agitated by new vivid visual hallucinations. The patient has become quite frightened by these visions and has started carrying a knife for protection. Delirium, dementia and medication effects are all ruled out as potential causes.

Her medical history is significant for vision loss secondary to macular degeneration and diabetic retinopathy, as well as diabetes, hypothyroidism, and a herniated disc. In terms of her mental health she reports feeling anxious and experiencing a sleep disturbance due to her fears. She also reports feeling sad and worthless as she cannot hear or see as well when she was younger.

Can you come up with a diagnosis or treatment plan?

"Terrifying Visions" by Abdulmalek Sadehh, Veena Bhanot, and Cristian Sirbu (Current Psychiatry)

Think Like A Psychiatrist - Young, Pregnant and Ataxic

1/8/2015

Put your knowledge and skills to the test with the case of a 15 year old woman who is 35 weeks pregnant and presents to obstetrics triage with dizziness, tinnitus, headache, and difficult walking. All of her symptoms resolve after three days, except for her gait disturbance which persists. She is seen by neurology and otolaryngology which cannot identify a cause for her ataxia.

In further work-up, the patient reports that she was recently abandoned by her boyfriend after he learned about the pregnancy. The patient also has a history of depression and self-harm, but states she feels fine and does not believe she needs psychiatric care. While the patient does not endorse a history of trauma or symptoms suggestive of a mood, anxiety, or psychotic illness, she is observed to display childlike mannerisms and her aunt reports that she has become more dependent recently. She displays indifference to these recent stressors and demonstrates alexithymia.

Other noteworthy history include the fact that the patient was sent by her parents from Guatemala to the United States at age 5 in hopes that she would lead a better life than she would have had in Guatemala. The patient's cousin was also diagnosed with a cholesteatoma after he presented with symptoms similar to this patient's initial presentation a number of years back.

Can you come up with a diagnosis or treatment plan?

"Young, Pregnant, Ataxic-and Jilted'" by Nancy Byatt and Ramanpreet Toor (Current Psychiatry).