Transcript Case 47

CASE 47: BIPOLAR
DISORDER
By Ryan Raroque
Bipolar Disorder Spectrum
Chief Complaints

Older sister says: “Our mother died three weeks ago
and we lost our father several months ago. I think
that my sister was depressed and just wanted to be
with them.”
History of Present Illness
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31-year-old female
named B.J. brought to the
hospital by ambulance
Found slumped over in a
car in front of funeral
home
Two empty bottles of
sleeping pills and a Bible
opened to the 23rd Psalm
found on the seat beside
her
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Left a suicide note
Funeral home director
discovered her with her
hair oily and unkempt
Seemed like she hadn’t
bathed in a long time
Past Medical History
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Episodes of depression first
occurred as a junior in high
school
Admitted to psychiatric ward
at age 15 and 19
Met her first husband in psych
ward at age 19 following a
suicide attempt
Patient was treated with
antidepressants and
psychotherapy and
discharged on both occassions
after approximately 5 weeks
Interview with Patient’s Older Sister
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Parents were both
alcoholics
State took kids away
and sent them to foster
homes
Some kids were
beaten or sexually
abused
Interview with Patient’s Older Sister
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B.J. has been in several
detoxification centers
for alcohol abuse
Is in her second
marriage
Has three daughters
Interview with Patient’s Older Sister
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B.J. was diagnosed with BD about six years ago
Fell into a terrible depression after giving birth to
her third child
Responded negatively to antidepressants
 “She
told me that movie stars were talking to her
whenever she went to the movies”
 “Her speech became impossible to understand”
 “She would stay up all night and just pace about the
house”
Interview with Patient’s Older Sister
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Doctors initially thought she had a thyroid condition,
but it turned out to be BD
B.J. would sometimes call her at 3 AM to talk
 Cycled
between being hostile/sarcastic and apologetic
 Rambled and “preached” about random topics

Family tried to convince her she
needed help, but she believed
she was absolutely fine
Interview with Patient’s Older Sister

According to B.J.: “You’re all just jealous because I’m
finally happy and feeling good about myself”
 Went
on shopping sprees 2-3 days at a time and max
out her credit cards
 Family tried to tell her that this was dangerous behavior
but she wouldn’t listen

When she finally “crashed,” she was taken to the
hospital and diagnosed with BD
Interview with Patient’s Older Sister
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Had been taking lithium ever since and was fine
until recently
Death of parents marked the beginning of a
downward spiral
Had been losing a lot of weight
Was drinking and smoking more than usual
Family History
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Strong history of mental illness – paternal grandmother suffered from
depression; two maternal aunts diagnosed with bipolar disorder
Both parents have died – her father from pancreatic cancer that had
metastasized to bone and her mother from heart failure
Both parents had a long history of alcohol abuse
Father was previously diagnosed with pancreatitis and then diabetes
mellitus for which he had been taking insulin
Mother had been relatively well (except for a “smoker’s cough”) with few
serious medical problems until her husband’s death; some said that she
“died from a broken heart”
Patient has 3 living brothers, 3 living sisters, and 3 daughters
One brother died from AMI at age 34; another brother died at 6 moths
from “water on the brain”
Social History
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Divorced and remarried
Has worked primarily as a nurse’s aide and more,
recently, as a health insurance claims adjuster
Is religious and goes to church regularly
Has smoked 1 ppd for nearly 15 years
Has history of alcohol abuse with several Driving
While Intoxicated violations
History of IVDA but has not used for more than 10
years
Medications
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Lithium 600 mg po Q AM and 600 mg po Q HS
Sumatriptan 50-200 mg po PRN
Allergies
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ASA -> Swelling of
face
Review of Systems
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Migraine headaches,
2-3/month
(-) for aura but (+) for
nausea, vomiting, and
photophobia
PE and Lab Tests
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Performed three hours
after gaining
consciousness
Gen
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Patient is tired-looking,
white female in NAD
Very pale
“Dark rings” under her
eyes
Vital Signs
BP
110/72 (supine)
RR
16 and unlabored HT/WT
P
81 and regular
T
98.6 °F
5’6’’/135 lbs
SaO2 97% on room air
Patient Case Questions
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
Are any of the patient’s vital signs significantly
abnormal?
Why has the patient been taking sumatriptan as
needed?
Identify this patient’s two most significant risk factors
for bipolar disorder.
Identify two additional potential contributing factors
to bipolar disorder in this patient.
Patient Case Questions




Are any of the patient’s vital signs significantly
abnormal?
Why has the patient been taking sumatriptan as
needed?
Identify this patient’s two most significant risk factors
for bipolar disorder.
Identify two additional potential contributing factors
to bipolar disorder in this patient.
Vital Signs
BP
110/72 (supine)
RR
16 and unlabored HT/WT
P
81 and regular
T
98.6 °F
5’6’’/135 lbs
SaO2 97% on room air
Vital Signs
BP
110/72 (supine)
RR
16 and unlabored HT/WT
P
81 and regular
T
98.6 °F
5’6’’/135 lbs
SaO2 97% on room air
Patient Case Questions




Are any of the patient’s vital signs significantly
abnormal?
Why has the patient been taking sumatriptan as
needed?
Identify this patient’s two most significant risk factors
for bipolar disorder.
Identify two additional potential contributing factors
to bipolar disorder in this patient.
Allergies

ASA -> Swelling of
face
Review of Systems


Migraine headaches,
2-3/month
(-) for aura but (+) for
nausea, vomiting, and
photophobia
Allergies

ASA -> Swelling of
face
Review of Systems
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Migraine headaches,
2-3/month
(-) for aura but (+) for
nausea, vomiting, and
photophobia
Patient Case Questions




Are any of the patient’s vital signs significantly
abnormal?
Why has the patient been taking sumatriptan as
needed?
Identify this patient’s two most significant risk factors
for bipolar disorder.
Identify two additional potential contributing factors
to bipolar disorder in this patient.
Significant Risk Factors
Significant Risk Factors
Significant Risk Factors
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Genetics
Environment
Patient Case Questions




Are any of the patient’s vital signs significantly
abnormal?
Why has the patient been taking sumatriptan as
needed?
Identify this patient’s two most significant risk factors
for bipolar disorder.
Identify two additional potential contributing factors
to bipolar disorder in this patient.
Skin
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Comedones on
forehead, nose, and
chin with several cystic
lesions on chin
Normal turgor
Soft, intact, warm, dry,
and very pale
No evidence of rash,
ecchymoses, petechiae,
or cyanosis
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Head
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Normocephalic and
atraumatic
Eyes
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PERRLA
EOMI
Funduscopy revealed
normal, clear disc margins
without lesions
(-) nystagmus
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Ears
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Nose
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(-) discharge or congestion
Throat
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TMs intact
(-) exudates or erythema
Dry mucous membranes
Neck
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Supple
No enlarged nodes,
thyromegaly, bruits, or
jugular venous distention
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Heart
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RRR
 S1 and S2 normal
without additional
cardiac sounds
(+) BS
 (-) pain or tenderness
 Soft and non-distended
 (-) hepatomegaly,
splenomegaly, masses,
bruits
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Lungs
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Abd
CTA & P bilaterally
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Breasts
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Exam deferred
Genit/Rect
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Exam deferred
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MS/Ext
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Full ROM
Distal pulses normal at 2+
bilaterally
(-) edema, cyanosis,
clubbing
No joint swelling or
tenderness
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Neuro
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Slightly lethargic but
oriented to person, place,
and time
Deep tendon reflexes full
and symmetric
Babinski negative
bilaterially
Normal strength throughout
Sensation intact
CNs II-XII intact
Speech: No dysarthria,
rate normal
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Neuro (contd)
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Gross and fine motor
coordination are normal
Cerebellar: finger-to-nose
and heel-to-shin WNL
Able to toe and tandem
walk without difficulty
Gait normal in speed and
step length
Able to perform serial 7s
and can abstract
Short and long-term
memories intact
Case Questions
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Does this patient have any signs of abnormal renal
function?
Does this patient have any signs of abnormal
hepatic function?
Case Questions
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Does this patient have any signs of abnormal renal
function?
Does this patient have any signs of abnormal
hepatic function?
Patient Case Table 47.2 Laboratory Blood Test Results
Na
139 meq/L
MCV
90.2 fl
Bilirubin, total
K
3.7 meq/L
MCH
31 pg
Alb
2.9 g/dL
Cl
108 meq/L
MCHC
Protein, total
4.8g/dL
HCO3
23 meq/L
Plt
BUN
10 mg/dL
WBC
Cr
0.7 mg/dL
Diff
34.4 g/dL
Glu, fasting
150,000/mm3
Ca
8.7 mg/dL
9,400/mm3
Mg
2.0 mg/dL
Lithium
• Neutros
• Lymphs
• Monos
• Eos
• Basos
0.7 mg/dL
65%
25%
7%
2%
1%
0.08 meq/L
Steady-state serum lithium concentrations
should always be maintained at a
concentration of 0.6-1.2 meq/L
102 mg/dL
AST
33 IU/L
Phos
3.2 mg/dL
Hb
12.2 g/dL
ALT
20 IU/L
TSH
4.1 µU/mL
Hct
36.8%
Alk Phos
59 IU/L
Cortisol @ 8AM
9.3µg/dL
GGT
82 IU/L
Vitamin B12
RBC
4.73 x 106/mm3
203 pg/mL
Patient Case Table 47.2 Laboratory Blood Test Results
Na
139 meq/L
MCV
90.2 fl
Bilirubin, total
K
3.7 meq/L
MCH
31 pg
Alb
2.9 g/dL
Cl
108 meq/L
MCHC
Protein, total
4.8g/dL
HCO3
23 meq/L
Plt
BUN
10 mg/dL
WBC
Cr
0.7 mg/dL
Diff
34.4 g/dL
150,000/mm3
Ca
8.7 mg/dL
9,400/mm3
Mg
2.0 mg/dL
According to the NationalLithium
Institute of Health, 0.08
a meq/L
between 6-20mg/dL.
•normal
Neutros BUN value is65%
• Lymphs
• Monos
•AEosnormal
• Basos
women.
Glu, fasting
0.7 mg/dL
Cr is
25% Steady-state serum lithium concentrations
7% should always be maintained at a
between
and 1.1
mg/dL
for
2% 0.6
concentration
of 0.6-1.2
meq/L
1%
102 mg/dL
AST
33 IU/L
Phos
3.2 mg/dL
Hb
12.2 g/dL
ALT
20 IU/L
TSH
4.1 µU/mL
Hct
36.8%
Alk Phos
59 IU/L
Cortisol @ 8AM
9.3µg/dL
GGT
82 IU/L
Vitamin B12
RBC
4.73 x 106/mm3
203 pg/mL
Case Questions
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Does this patient have any signs of abnormal renal
function?
Does this patient have any signs of abnormal
hepatic function?
Patient Case Table 47.2 Laboratory Blood Test Results
Na
139 meq/L
MCV
90.2 fl
Bilirubin, total
K
3.7 meq/L
MCH
31 pg
Alb
2.9 g/dL
Cl
108 meq/L
MCHC
Protein, total
4.8g/dL
HCO3
BUN
Cr
Normal ranges according to NIH:
23 meq/L
Plt
Bilirubin: 0.3 to101.9
mg/dL
mg/dL WBC
Albumin: 3.4 - 5.4 g/dL
0.7 mg/dL
150,000/mm3
Ca
8.7 mg/dL
9,400/mm3
Mg
2.0 mg/dL
Diff
AST: 10 to 34 IU/L.
ALT: 10 to 40 IU/L
Alk Phos: 44 to 147 IU/L
GGT: 0 to 51 IU/L
Glu, fasting
34.4 g/dL
Lithium
• Neutros
• Lymphs
• Monos
• Eos
• Basos
0.7 mg/dL
65%
25%
7%
2%
1%
0.08 meq/L
Steady-state serum lithium concentrations
should always be maintained at a
concentration of 0.6-1.2 meq/L
102 mg/dL
AST
33 IU/L
Phos
3.2 mg/dL
Hb
12.2 g/dL
ALT
20 IU/L
TSH
4.1 µU/mL
Hct
36.8%
Alk Phos
59 IU/L
Cortisol @ 8AM
9.3µg/dL
GGT
82 IU/L
Vitamin B12
RBC
4.73 x 106/mm3
203 pg/mL
Patient Case Table 47.2 Laboratory Blood Test Results
Na
139 meq/L
MCV
90.2 fl
Bilirubin, total
K
3.7 meq/L
MCH
31 pg
Alb
2.9 g/dL
Cl
108 meq/L
MCHC
Protein, total
4.8g/dL
HCO3
BUN
Cr
Normal ranges according to NIH:
23 meq/L
Plt
Bilirubin: 0.3 to101.9
mg/dL
mg/dL WBC
Albumin: 3.4 - 5.4 g/dL
0.7 mg/dL
150,000/mm3
Ca
8.7 mg/dL
9,400/mm3
Mg
2.0 mg/dL
Diff
AST: 10 to 34 IU/L.
ALT: 10 to 40 IU/L
Alk Phos: 44 to 147 IU/L
GGT: 0 to 51 IU/L
Glu, fasting
34.4 g/dL
Lithium
• Neutros
• Lymphs
• Monos
• Eos
• Basos
0.7 mg/dL
65%
25%
7%
2%
1%
0.08 meq/L
Steady-state serum lithium concentrations
should always be maintained at a
concentration of 0.6-1.2 meq/L
102 mg/dL
AST
33 IU/L
Phos
3.2 mg/dL
Hb
12.2 g/dL
ALT
20 IU/L
TSH
4.1 µU/mL
Hct
36.8%
Alk Phos
59 IU/L
Cortisol @ 8AM
9.3µg/dL
GGT
82 IU/L
Vitamin B12
RBC
4.73 x 106/mm3
203 pg/mL
Case Questions
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Identify this patient’s three most significant
abnormal blood laboratory test results and propose
a reasonable explanation for these results.
What is suggested by the patient’s serum TSH,
cortisol, and vitamin B12 concentrations?
Case Questions


Identify this patient’s three most significant
abnormal blood laboratory test results and propose
a reasonable explanation for these results.
What is suggested by the patient’s serum TSH,
cortisol, and vitamin B12 concentrations?
Abnormal Blood Test Results
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Less-than-normal albumin levels
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Elevated GGT
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Lithium concentration in serum below steady-state
levels
Lithium
0.08 meq/L
Steady-state serum lithium concentrations should
always be maintained at a concentration of
0.6-1.2 meq/L
Case Questions


Identify this patient’s three most significant
abnormal blood laboratory test results and propose
a reasonable explanation for these results.
What is suggested by the patient’s serum TSH,
cortisol, and vitamin B12 concentrations?
Patient Case Table 47.2 Laboratory Blood Test Results
Na
139 meq/L
MCV
90.2 fl
Bilirubin, total
K
3.7 meq/L
MCH
31 pg
Alb
2.9 g/dL
Cl
108 meq/L
MCHC
Protein, total
4.8g/dL
HCO3
23 meq/L
Plt
BUN
10 mg/dL
WBC
Cr
0.7 mg/dL
Diff
34.4 g/dL
Glu, fasting
150,000/mm3
Ca
8.7 mg/dL
9,400/mm3
Mg
2.0 mg/dL
Lithium
• Neutros
• Lymphs
• Monos
• Eos
• Basos
0.7 mg/dL
65%
25%
7%
2%
1%
0.08 meq/L
Steady-state serum lithium concentrations
should always be maintained at a
concentration of 0.6-1.2 meq/L
102 mg/dL
AST
33 IU/L
Phos
3.2 mg/dL
Hb
12.2 g/dL
ALT
20 IU/L
TSH
4.1 µU/mL
Hct
36.8%
Alk Phos
59 IU/L
Cortisol @ 8AM
9.3µg/dL
GGT
82 IU/L
Vitamin B12
RBC
4.73 x 106/mm3
203 pg/mL
Patient Case Table 47.3 Urinalysis
Color
Yellow
SG
1.021
Appearance
Cloudy
Blood
Negative
Glucose
Negative
pH
6.3
Bilirubin
Negative
Protein
Negative
Ketones
Negative
Nitrites
Negative
Case Questions


List a minimum of eight clinical manifestations
observed in this patient that were helpful toward an
initial diagnosis of bipolar disorder.
Identify all signs of brain damage that may have
occurred from the patient’s most recent suicide
attempt.
Case Questions


List a minimum of eight clinical manifestations
observed in this patient that were helpful toward an
initial diagnosis of bipolar disorder.
Identify all signs of brain damage that may have
occurred from the patient’s most recent suicide
attempt.
Clinical Manifestations
Clinical Manifestations
Feature Assessed
Major Depressive Episode
Major Manic Episode
Appearance
Talks fast
Movement
Hyperactive and restless
Affect/Mood
Sadness
Helplessness
Hopelessness
Isolation
Emptiness
Thought
Inappropriately joyous,
elated, jubilant
Rapid shifting of ideas
Perceptions
Hallucinations
Suicide
Attempted it once before
Aggression
No patience or tolerance
for others
Judgment
Poor financial investments,
doesn’t listen to advice,
poor insight on behavior
Case Questions


List a minimum of eight clinical manifestations
observed in this patient that were helpful toward an
initial diagnosis of bipolar disorder.
Identify all signs of brain damage that may have
occurred from the patient’s most recent suicide
attempt.
Signs of Brain Damage
Neurological exam
turned out fine
Review of Systems


Migraine headaches,
2-3/month
(-) for aura but (+) for
nausea, vomiting, and
photophobia
Case Questions


Does the patient in this case study require inpatient
treatment or is outpatient therapy totally
appropriate?
Do you think that the prognosis for this patient is
favorable or less than favorable?
Case Questions


Does the patient in this case study require inpatient
treatment or is outpatient therapy totally
appropriate?
Do you think that the prognosis for this patient is
favorable or less than favorable?
Case Questions


Does the patient in this case study require inpatient
treatment or is outpatient therapy totally
appropriate?
Do you think that the prognosis for this patient is
favorable or less than favorable?
Prognosis
Favorable
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Late age of onset
Few thoughts of suicide
Few psychotic
symptoms
Few medical problems
Less Than Favorable
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Poor job history
Alcohol abuse
Psychotic features
Early age of onset
Complications: poor
judgment and decision
making, substance
abuse, risky behaviors