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
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
