MS-III
Tuesday, April 19, 2005
Patient Files: Volume 1
Patient: R.B.
Age: 29
Sex: Male
Race: Caucasian
Date of Admission: 4/19/2005
History of Present Illness:
Mr. B. is a 29 year old caucasian male admitted from the Psych ER on detention warrant from home where he was found by police to be running around his mother's house yelling that "someone brown is chasing me with a gun."
The police searched Mr. B and the surrounding premises but were unable to find any weapons. Upon speaking with his mother, it was found that Mr. B had become progressively paranoid after running out of his Risperdal 3 days ago. They also discovered he has carried a diagnosis of paranoid schizophrenia for the past 3 months after being diagnosed at a hospital in his hometown. He has been taking Risperdal 2 mg po BID, Paxil 20 po QD, and an unknown dose of Atarax since that time - until 3 days ago when he ran out of Risperdal.
Because of his increasing paranoia (and psych history), the police officer took Mr. B into custody and brought him to the Psych ER for evaluation.
In the Psych ER, Mr. B was aggressive and not cooperative. He said he knows someone is trying to kill him and that he cannot stay there. He also made references to being psychic and made the comment, "See all these buildings, they will not be here soon."
Mr. B denies any suicidal or homicidal ideation. He repeatedly stated, "I get like this when I'm off my medication," and frequently requested that he be re-started on his medication.
Upon continuation of the diagnosis of Paranoid Schizophrenia, Mr. B was admitted to the inpatient psychiatric facility for further evaluation and treatment.
PMH:
Mr. B denies any past medical history
Past Psych Hx:
None, other than the above noted hospitalization and diagnosis of paranoid schizophrenia. He denies ever taking any other psych meds than the ones he is currenly taking: Risperdal, Paxil, and Atarax.
Social Hx:
Married x 5 years. One child (2 year old son), currently living in his hometown with his wife. Mr. B is currently living with his mother as he works in concrete construction to pay for a house he is buying back in his hometown. Denies any arrests or legal trouble.
Past Substance Abuse Hx:
Denies tobacco, alcohol, and illicit drug use
Family Hx:
Significant for cancer (breast, prostate) and hypertension.
Labs: - (obtained after admission) -
CBC: Within Normal Limits (WNL)
CMP: WNL
DAU: + methamphetamines; - cocaine, cannabis, benzos, opioids
TSH: WNL
Upon further repeated questioning and confrontation, it was discovered that Mr. B had indeed used methamphetamines 2 days before admission, although he denied regular recent use. He admitted to frequent use 2-3 years ago, along with cannabis use. He claims to have only smoked amphetamines, never used them intravenously.
He still claims to be out of his risperdal for the past 3 days, and denies that methamphetamine use could be the cause of his symptoms.
Discussion:
After further review, Mr. B's most likely diagnosis is Substance-induced Psychotic disorder. However, at this time, paranoid schizophrenia cannot be ruled out. This brings up an important point - whenever making any psychiatric diagnosis, two things must always be ruled out:
1. The psychiatric disorder cannot be caused by another medical condition
2. The psychiatric disorder cannot be the result of drug use
This is very important to remember, because many drugs and medical conditions can look very much like psychiatric disorders. The classic examples are amphetamine use and bipolar disorder/manic episode, hypothyroidism and depression, and cocaine abuse and psychosis. Distinguishing these can often be difficult in an acute setting, which is why NOS diagnoses are so common in the acute period. This non-comittal diagnosis gives the physician time to sort out the details needed to make a more informed final diagnosis.
This also points out the danger in simply 'carrying forward' a diagnosis another physician has given a patient - especially a new diagnosis. While Mr. B's psychosis may be due to paranoid schizophrenia, in the setting of recent drug use, we cannot make this diagnosis for sure until all effects of the drug have worn off and we see his baseline mental status.
Treatment:
The treatment of psychosis depends on its cause.
If drug induced, one must simply wait until the drug effects wear off, with symptomatic medications used only for agitation and violence. In this case, a typical antipsychotic (haloperidol) along with a benzodiazepine (lorazepam) and an antihistaminic/anticholinergic (diphenhydramine) cocktail may be given intramuscularly to sedate and calm a patient.
When using typical antipsychotics, one must remember to watch for Neuroleptic Malignant Syndrome (NMS), which is a dangerous, sometimes life threatening idiosyncratic reaction to antipsychotic medications. In NMS, the patient's temperature rises, he develops muscular rigidity (lead-pipe or cog-wheel), increased agitation, and elevations in blood pressure and pulse rates. He usually develops rhabdomyolysis (mild to severe) and may develop myoglobinuria and acute renal failure. It is important to determine whether an increase in agitation is just that or the early signs of NMS, since if it is wrongly determined to be increased agitation and further doses of antipsychotics are given, NMS may be worsened. NMS is more common in young men and with recent onset of use of typical antipsychotics.
If psychosis is caused by another medical condition, such as porphyria, temporal lobe epilepsy, or other medical condition, treatment of the medical problem will usually result in resolution of the psychosis.
If psychosis is determined to be caused by a mood disorder, appropriate treatment of the mood disorder (with interval treatment with antipsychotic medications) will result in resolution of the psychosis.
If it is caused by schizophrenia (or other psychotic disorder), treatment with antipsychotic medications is the best treatment. Antipsychotic medications come in two varieties: typical and atypical.
Typical antipsychotics (aka neuroleptics) are older, cheaper and have more side effects. They are dopamine receptor antagonists, and thereby have all the problems associated with dopamine blockade: parkinsonism, other movement disorders, hyperprolactinemia, etc. However, they work very well for what are called the "positive" psychotic symptoms. These include hallucinations and delusions - things that are there and are not supposed to be (positive means added). These drugs all cause sedation and have varying degrees of anticholinergic and antihistaminic effects as well.
Atypical antipsychotics are newer, more expensive, but have the added bonus of being cleaner (i.e. fewer side effects) and they are more effective against the "negative" psychotic symptoms. These include flat affect, thought blocking, alogia, apraxia, psychomotor retardation, lack of self care, poverty of speech/thought - things that should be there and are not (negative means taken away). These drugs are thought to work by interacting with sertotonergic receptors rather than dopaminergic receptors (although they do that as well - although to a lesser degree than the typicals). This is partly why they have fewer of the icky side-effects of the typicals. It is believed that by altering the serotonin levels in the limbic system and basal ganglia, norepinephrine levels will increase - causing an improvement in negative symptoms. The little bit of dopamine antagonism these drugs have also help take care of the positive symptoms of psychosis.
The boo-bad thing about the atypical drugs is that they have freaky side-effects. For example, clozapine causes agranulocytosis in about 1% of the people that take it. Not too good. As a result, the patient has to have blood tests weekly for the first 6 months they take it, then every 2 weeks thereafter. Kind of a pain in the butt. Another of the atypicals, olanzapine, causes problems with weight gain, insulin resistance, and increased LDL cholesterol - so if you have a patient with metabolic syndrome or diabetes (or even a strong family history) you'd better not give them this drug unless you want to be sitting in a court-room pretty soon.
But even with these side-effects, these drugs have turned many people's lives around for the better.
Follow-Up:
After 1 day of inpatient treatment, Mr. B's psychosis cleared. He was restarted on his Risperdal and his Paxil and Atarax were continued per his request. Given his rapid return to baseline, it was felt that his psychosis was indeed most likely caused by amphetamine use. However, because we have no way of determining his true psychiatric history at this time, his psychotropic medications have been continued. We are currently awaiting records from his private psychiatrist before any further determinations are made.
-----------------------------------------------------------------------------------------
Ok. Here ends Volume 1 of The Patient Files. As you've seen above, the cases will most likely reflect what I am seeing on my current rotation, since I can't remember many details of past patients. Please feel free to ask questions about the cases or post your own cases.
I've had fun with this - and it helps me refresh my memory for the shelf later.. how better to learn than to teach, right?
Enjoy!! ¶ 9:34 AM 0 comments
Age: 29
Sex: Male
Race: Caucasian
Date of Admission: 4/19/2005
History of Present Illness:
Mr. B. is a 29 year old caucasian male admitted from the Psych ER on detention warrant from home where he was found by police to be running around his mother's house yelling that "someone brown is chasing me with a gun."
The police searched Mr. B and the surrounding premises but were unable to find any weapons. Upon speaking with his mother, it was found that Mr. B had become progressively paranoid after running out of his Risperdal 3 days ago. They also discovered he has carried a diagnosis of paranoid schizophrenia for the past 3 months after being diagnosed at a hospital in his hometown. He has been taking Risperdal 2 mg po BID, Paxil 20 po QD, and an unknown dose of Atarax since that time - until 3 days ago when he ran out of Risperdal.
Because of his increasing paranoia (and psych history), the police officer took Mr. B into custody and brought him to the Psych ER for evaluation.
In the Psych ER, Mr. B was aggressive and not cooperative. He said he knows someone is trying to kill him and that he cannot stay there. He also made references to being psychic and made the comment, "See all these buildings, they will not be here soon."
Mr. B denies any suicidal or homicidal ideation. He repeatedly stated, "I get like this when I'm off my medication," and frequently requested that he be re-started on his medication.
Upon continuation of the diagnosis of Paranoid Schizophrenia, Mr. B was admitted to the inpatient psychiatric facility for further evaluation and treatment.
PMH:
Mr. B denies any past medical history
Past Psych Hx:
None, other than the above noted hospitalization and diagnosis of paranoid schizophrenia. He denies ever taking any other psych meds than the ones he is currenly taking: Risperdal, Paxil, and Atarax.
Social Hx:
Married x 5 years. One child (2 year old son), currently living in his hometown with his wife. Mr. B is currently living with his mother as he works in concrete construction to pay for a house he is buying back in his hometown. Denies any arrests or legal trouble.
Past Substance Abuse Hx:
Denies tobacco, alcohol, and illicit drug use
Family Hx:
Significant for cancer (breast, prostate) and hypertension.
Labs: - (obtained after admission) -
CBC: Within Normal Limits (WNL)
CMP: WNL
DAU: + methamphetamines; - cocaine, cannabis, benzos, opioids
TSH: WNL
Upon further repeated questioning and confrontation, it was discovered that Mr. B had indeed used methamphetamines 2 days before admission, although he denied regular recent use. He admitted to frequent use 2-3 years ago, along with cannabis use. He claims to have only smoked amphetamines, never used them intravenously.
He still claims to be out of his risperdal for the past 3 days, and denies that methamphetamine use could be the cause of his symptoms.
Discussion:
After further review, Mr. B's most likely diagnosis is Substance-induced Psychotic disorder. However, at this time, paranoid schizophrenia cannot be ruled out. This brings up an important point - whenever making any psychiatric diagnosis, two things must always be ruled out:
1. The psychiatric disorder cannot be caused by another medical condition
2. The psychiatric disorder cannot be the result of drug use
This is very important to remember, because many drugs and medical conditions can look very much like psychiatric disorders. The classic examples are amphetamine use and bipolar disorder/manic episode, hypothyroidism and depression, and cocaine abuse and psychosis. Distinguishing these can often be difficult in an acute setting, which is why NOS diagnoses are so common in the acute period. This non-comittal diagnosis gives the physician time to sort out the details needed to make a more informed final diagnosis.
This also points out the danger in simply 'carrying forward' a diagnosis another physician has given a patient - especially a new diagnosis. While Mr. B's psychosis may be due to paranoid schizophrenia, in the setting of recent drug use, we cannot make this diagnosis for sure until all effects of the drug have worn off and we see his baseline mental status.
Treatment:
The treatment of psychosis depends on its cause.
If drug induced, one must simply wait until the drug effects wear off, with symptomatic medications used only for agitation and violence. In this case, a typical antipsychotic (haloperidol) along with a benzodiazepine (lorazepam) and an antihistaminic/anticholinergic (diphenhydramine) cocktail may be given intramuscularly to sedate and calm a patient.
When using typical antipsychotics, one must remember to watch for Neuroleptic Malignant Syndrome (NMS), which is a dangerous, sometimes life threatening idiosyncratic reaction to antipsychotic medications. In NMS, the patient's temperature rises, he develops muscular rigidity (lead-pipe or cog-wheel), increased agitation, and elevations in blood pressure and pulse rates. He usually develops rhabdomyolysis (mild to severe) and may develop myoglobinuria and acute renal failure. It is important to determine whether an increase in agitation is just that or the early signs of NMS, since if it is wrongly determined to be increased agitation and further doses of antipsychotics are given, NMS may be worsened. NMS is more common in young men and with recent onset of use of typical antipsychotics.
If psychosis is caused by another medical condition, such as porphyria, temporal lobe epilepsy, or other medical condition, treatment of the medical problem will usually result in resolution of the psychosis.
If psychosis is determined to be caused by a mood disorder, appropriate treatment of the mood disorder (with interval treatment with antipsychotic medications) will result in resolution of the psychosis.
If it is caused by schizophrenia (or other psychotic disorder), treatment with antipsychotic medications is the best treatment. Antipsychotic medications come in two varieties: typical and atypical.
Typical antipsychotics (aka neuroleptics) are older, cheaper and have more side effects. They are dopamine receptor antagonists, and thereby have all the problems associated with dopamine blockade: parkinsonism, other movement disorders, hyperprolactinemia, etc. However, they work very well for what are called the "positive" psychotic symptoms. These include hallucinations and delusions - things that are there and are not supposed to be (positive means added). These drugs all cause sedation and have varying degrees of anticholinergic and antihistaminic effects as well.
Atypical antipsychotics are newer, more expensive, but have the added bonus of being cleaner (i.e. fewer side effects) and they are more effective against the "negative" psychotic symptoms. These include flat affect, thought blocking, alogia, apraxia, psychomotor retardation, lack of self care, poverty of speech/thought - things that should be there and are not (negative means taken away). These drugs are thought to work by interacting with sertotonergic receptors rather than dopaminergic receptors (although they do that as well - although to a lesser degree than the typicals). This is partly why they have fewer of the icky side-effects of the typicals. It is believed that by altering the serotonin levels in the limbic system and basal ganglia, norepinephrine levels will increase - causing an improvement in negative symptoms. The little bit of dopamine antagonism these drugs have also help take care of the positive symptoms of psychosis.
The boo-bad thing about the atypical drugs is that they have freaky side-effects. For example, clozapine causes agranulocytosis in about 1% of the people that take it. Not too good. As a result, the patient has to have blood tests weekly for the first 6 months they take it, then every 2 weeks thereafter. Kind of a pain in the butt. Another of the atypicals, olanzapine, causes problems with weight gain, insulin resistance, and increased LDL cholesterol - so if you have a patient with metabolic syndrome or diabetes (or even a strong family history) you'd better not give them this drug unless you want to be sitting in a court-room pretty soon.
But even with these side-effects, these drugs have turned many people's lives around for the better.
Follow-Up:
After 1 day of inpatient treatment, Mr. B's psychosis cleared. He was restarted on his Risperdal and his Paxil and Atarax were continued per his request. Given his rapid return to baseline, it was felt that his psychosis was indeed most likely caused by amphetamine use. However, because we have no way of determining his true psychiatric history at this time, his psychotropic medications have been continued. We are currently awaiting records from his private psychiatrist before any further determinations are made.
-----------------------------------------------------------------------------------------
Ok. Here ends Volume 1 of The Patient Files. As you've seen above, the cases will most likely reflect what I am seeing on my current rotation, since I can't remember many details of past patients. Please feel free to ask questions about the cases or post your own cases.
I've had fun with this - and it helps me refresh my memory for the shelf later.. how better to learn than to teach, right?
Enjoy!! ¶ 9:34 AM 0 comments
Wednesday, April 13, 2005
Psychosis and me
It was the best of times, it was the worst of times.
It was a month on the psychiatry service at the busy county hospital.
It's been a whole boat-load of fun so far. Let me tell you about it.
During our psychiatry rotation, we do 2 weeks on an inpatient unit and 2 weeks in the psych ER. I started with the psychiatric ER because I thought it sounded more fun than the inpatient side. Also, there was a rumor that the inpatient unit usually gets out early every day, so I thought it would be cool to have the time to study for the shelf in the last 2 weeks. So far, it has worked out pretty well for me.
The first 2 weeks, as I noted above, was spent in the psychiatric ER. This time is spent triaging patients that either present to the ER or are brought in by the police. Those that come on their own are called "voluntary" (obviously), while those that come in by the police are in on warrant. A warrant can be of two types: magistrate's warrant or detention warrant. The difference is that a Magistrate's warrant is initiated by a family member, roomate, etc when they are concerned for their family member or friend and a detention warrant is served by a peace officer when he or she feels that a person is a danger to himself or to other people.
So a person comes in voluntarily or is brought in by the police and is evaluated by a physician (or student). It is then determined what the best course of treatment would be for said patient, whether it be admission, discharge, referral to counselling, or drug rehab. The unfortunate thing is, many patients are shelter-seeking or drug-seeking and are very medicine-savvy, so the challenge is to determine when a patient is truly a danger to himself or others or whether they are in-fact malingering. Fortunately, many of the return patients are known to the department as recidivists, so are appropriately turned away when they come to the psych ER looking for 3 hots and a cot.
It is very interesting talking to patients when they have not previously been worked up and trying to come up with a good differential and provisional diagnosis. The problem with psychiatry is that many times one cannot make a definitive diagnosis because it is very difficult to gather all the required information from the patient and all involved relevant family members. As a result, many patients are dispositioned with a provisional diagnosis, such as Depression not otherwise specified (NOS), psychosis NOS, or mood disorder NOS. The two most common diagnoses in the actual psych ER (not the clinic or walk-in part of the psych ER) in my experience are psychosis NOS or substance-induced psychotic disorder.
Overall, this was a very exciting two weeks for me - I had a lot of autonomy since the student is truly the major caretaker for all the patients, and the attendings and residents have more of the role of consultant and advisors. By the end of the 2 weeks, I felt fairly comfortable in the psych ER, although there were always times I worried for my life. There are many crazy people here.
The second 2 weeks of the rotation are spent in the inpatient unit here at the county hospital. It serves people admitted from the psych ER - mostly those that are indigent and have no insurance. If they have insurance, most of them go to other facilities. This is very unfortunate, because I feel that the experience I am having is somewhat skewed because of the patient population I am serving. These people are medically underserved and therefore often have chronic medical problems that are uncontrolled on top of their psychiatric problems (or possibly causing their psychiatric problem).
The typical day on the inpatient unit is arriving between 7 and 730am, seeing the new patients that were admitted overnight and also re-evaluating the patients we already were seeing the days before. Then, we have all the patients come into the group with us (staff physician, residents, medical students and a social worker) and discuss their progress from the day before. Sometimes, there is some therapy that occurs at this time, usually minimal, and then we move on to the next patient. The cycle repeats itself until all the patients are seen in a day. If the patient is aggravated or dangerous, we see them on the unit where there are other people around to help if a situation arises.
This part of the rotation has been pretty boring to me thus far. I am not much for sitting around and talking to people in a group (mostly listening to people, since the attending does most of the talking). I haven't really cared for this part so much.
A couple things I have noticed since starting this rotation: 1) My problems are VERY VERY insignificant compared to these people's. This makes me feel much better about myself. 2) I have noticed in both myself and my classmates that are on the rotation with me, more psychiatric problems. I don't know if this is because I am more attuned to these clues or if being around the crazies induces craziness in others. Something like a shared psychosis (folie a deux - a truly excellent X-Files episode if you haven't seen it). I've always wondered if insanity could be communicable.
I know it isn't - but it is still a interesting thing to think about.
For instance, I have noticed more hypo-manic or manic symptoms in myself since starting this rotation. As I said before, I'm not sure that this isn't because I'm more savvy and recognize the symptoms more readily or whether there is, in fact, an increase in the symptoms. I think I'm usually a pretty "up" guy, but I don't think I'm usually as "up" as I have been the past couple of weeks. Weird association...
What do you think? Anyone else have a similar experience? ¶ 8:48 AM 0 comments
It was a month on the psychiatry service at the busy county hospital.
It's been a whole boat-load of fun so far. Let me tell you about it.
During our psychiatry rotation, we do 2 weeks on an inpatient unit and 2 weeks in the psych ER. I started with the psychiatric ER because I thought it sounded more fun than the inpatient side. Also, there was a rumor that the inpatient unit usually gets out early every day, so I thought it would be cool to have the time to study for the shelf in the last 2 weeks. So far, it has worked out pretty well for me.
The first 2 weeks, as I noted above, was spent in the psychiatric ER. This time is spent triaging patients that either present to the ER or are brought in by the police. Those that come on their own are called "voluntary" (obviously), while those that come in by the police are in on warrant. A warrant can be of two types: magistrate's warrant or detention warrant. The difference is that a Magistrate's warrant is initiated by a family member, roomate, etc when they are concerned for their family member or friend and a detention warrant is served by a peace officer when he or she feels that a person is a danger to himself or to other people.
So a person comes in voluntarily or is brought in by the police and is evaluated by a physician (or student). It is then determined what the best course of treatment would be for said patient, whether it be admission, discharge, referral to counselling, or drug rehab. The unfortunate thing is, many patients are shelter-seeking or drug-seeking and are very medicine-savvy, so the challenge is to determine when a patient is truly a danger to himself or others or whether they are in-fact malingering. Fortunately, many of the return patients are known to the department as recidivists, so are appropriately turned away when they come to the psych ER looking for 3 hots and a cot.
It is very interesting talking to patients when they have not previously been worked up and trying to come up with a good differential and provisional diagnosis. The problem with psychiatry is that many times one cannot make a definitive diagnosis because it is very difficult to gather all the required information from the patient and all involved relevant family members. As a result, many patients are dispositioned with a provisional diagnosis, such as Depression not otherwise specified (NOS), psychosis NOS, or mood disorder NOS. The two most common diagnoses in the actual psych ER (not the clinic or walk-in part of the psych ER) in my experience are psychosis NOS or substance-induced psychotic disorder.
Overall, this was a very exciting two weeks for me - I had a lot of autonomy since the student is truly the major caretaker for all the patients, and the attendings and residents have more of the role of consultant and advisors. By the end of the 2 weeks, I felt fairly comfortable in the psych ER, although there were always times I worried for my life. There are many crazy people here.
The second 2 weeks of the rotation are spent in the inpatient unit here at the county hospital. It serves people admitted from the psych ER - mostly those that are indigent and have no insurance. If they have insurance, most of them go to other facilities. This is very unfortunate, because I feel that the experience I am having is somewhat skewed because of the patient population I am serving. These people are medically underserved and therefore often have chronic medical problems that are uncontrolled on top of their psychiatric problems (or possibly causing their psychiatric problem).
The typical day on the inpatient unit is arriving between 7 and 730am, seeing the new patients that were admitted overnight and also re-evaluating the patients we already were seeing the days before. Then, we have all the patients come into the group with us (staff physician, residents, medical students and a social worker) and discuss their progress from the day before. Sometimes, there is some therapy that occurs at this time, usually minimal, and then we move on to the next patient. The cycle repeats itself until all the patients are seen in a day. If the patient is aggravated or dangerous, we see them on the unit where there are other people around to help if a situation arises.
This part of the rotation has been pretty boring to me thus far. I am not much for sitting around and talking to people in a group (mostly listening to people, since the attending does most of the talking). I haven't really cared for this part so much.
A couple things I have noticed since starting this rotation: 1) My problems are VERY VERY insignificant compared to these people's. This makes me feel much better about myself. 2) I have noticed in both myself and my classmates that are on the rotation with me, more psychiatric problems. I don't know if this is because I am more attuned to these clues or if being around the crazies induces craziness in others. Something like a shared psychosis (folie a deux - a truly excellent X-Files episode if you haven't seen it). I've always wondered if insanity could be communicable.
I know it isn't - but it is still a interesting thing to think about.
For instance, I have noticed more hypo-manic or manic symptoms in myself since starting this rotation. As I said before, I'm not sure that this isn't because I'm more savvy and recognize the symptoms more readily or whether there is, in fact, an increase in the symptoms. I think I'm usually a pretty "up" guy, but I don't think I'm usually as "up" as I have been the past couple of weeks. Weird association...
What do you think? Anyone else have a similar experience? ¶ 8:48 AM 0 comments
