What is a psychiatric case?

A 74-year-old African American woman, Ms. Richardson, was brought to the hospital emergency room by the police. She is unkempt, dirty, and foul-smelling. She does not look at the interviewer and is apparently confused and unresponsive to most of his questions. She knows her name and address, but not the day of the month. She is unable to describe the events that led to her admission.

The police reported that they were called by neighbors because Ms. Richardson had been wandering around the neighborhood and not taking care of herself. The medical center mobile crisis unit went to her house twice but could not get in and presumed she was not home. Finally, the police came and broke into the apartment, where they were met by a snarling German shepherd. They shot the dog with a tranquilizing gun and then found Ms. Richardson hiding in the corner, wearing nothing but a bra. The apartment was filthy, the floor littered with dog feces. The police found a gun, which they took into custody. The following day, while Ms. Richardson was awaiting transfer to a medical unit for treatment of her out-of-control diabetes, the psychiatric provider attempted to interview her. Her facial expression was still mostly unresponsive, and she still didnt know the month and couldnt say what hospital she was in. She reported that the neighbors had called the police because she was sick, and indeed she had felt sick and weak, with pains in her shoulder; in addition, she had not eaten for 3 days. She remembered that the police had shot her dog with a tranquilizer and said the dog was now in the shop and would be returned to her when she got home. She refused to give the name of a neighbor who was a friend, saying, hes got enough troubles of his own. She denied ever being in a psychiatric hospital or hearing voices but acknowledged that she had at one point seen a psychiatrist near downtown because she couldnt sleep. He had prescribed medication that was too strong, so she didnt take it. She didnt remember the name, so the interviewer asked if it was Thorazine. She said no, it was allal. Haldol?, ask the interviewer. She nodded.

The interviewer was convinced that was the drug, but other observers thought she might have said yes to anything that sounded remotely like it, such as Elavil. When asked about the gun, she denied, with some annoyance, that it was real and said it was a toy gun that had been brought to the house by her brother, who had died 8 years ago. She was still feeling weak and sick, complained of pain in her shoulder, and apparently had trouble swallowing. She did manage to smile as the team left her bedside.

Remember to answer these questions from your textbooks and clinical guidelines to create your evidence-based treatment plan. At all times, explain your answers.
Summarize the clinical case including the significant subjective and objective data.
Generate a primary and two differential diagnoses. Use the DSM5 to support the assessment. Include the DSM5 and ICD 10 codes.
Discuss a pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
Discuss non-pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
Describe a health promotion intervention that would be appropriate for this patient.

Full Answer Section

       

Primary and Differential Diagnoses

Primary Diagnosis:

  • Major Depressive Disorder, Recurrent, Severe, with Psychotic Features (DSM-5 Code: 296.23): This diagnosis is supported by the patient's symptoms of depressed mood, anhedonia, psychomotor retardation, and psychotic symptoms (delusions about the gun).

Differential Diagnoses:

  1. Delirium Due to Unspecified Medical Condition (DSM-5 Code: 780.09): This is a possibility given the patient's medical condition (diabetes) and altered mental status. However, the presence of psychotic symptoms and a history of depression make Major Depressive Disorder a more likely diagnosis.
  2. Schizophrenia (DSM-5 Code: 295.10): While psychotic symptoms are present, the lack of a persistent history of psychotic symptoms and the presence of a significant medical condition make this diagnosis less likely.

Pharmacological Treatment

Given the diagnosis of Major Depressive Disorder with Psychotic Features, the following pharmacological treatment is recommended:

  • Antidepressant Medication: A selective serotonin reuptake inhibitor (SSRI) such as sertraline or fluoxetine can be considered as first-line treatment. However, due to the patient's age and medical comorbidities, a more conservative approach with a tricyclic antidepressant (TCA) like nortriptyline or a serotonin-norepinephrine reuptake inhibitor (SNRI) like duloxetine may be appropriate.
  • Antipsychotic Medication: An antipsychotic medication, such as risperidone or olanzapine, can be added to address the psychotic symptoms.

Non-Pharmacological Treatment

  • Psychotherapy: Cognitive-behavioral therapy (CBT) can be beneficial in addressing negative thoughts and behaviors associated with depression. However, given the patient's current mental state, a more supportive approach, such as supportive therapy, may be more appropriate initially.
  • Social Work Intervention: A social worker can help address the patient's social and environmental needs, such as arranging for home care and connecting her with community resources.

Health Promotion Intervention

  • Diabetes Management: The patient should be referred to an endocrinologist for optimal management of her diabetes.
  • Nutrition and Hydration: A registered dietitian can provide guidance on a healthy diet to improve the patient's overall health.
  • Regular Medical Check-ups: The patient should be encouraged to schedule regular medical check-ups to monitor her health and address any emerging issues.

It's important to note that this is a general treatment plan and individualization is key. A comprehensive assessment by a mental health professional is necessary to determine the most appropriate treatment plan for this patient.

 

Sample Answer

     

Summary of the Clinical Case

Subjective Data:

  • Chief Complaint: Unkempt appearance, confusion, and weakness.
  • History of Present Illness: Recent history of wandering, neglect of self-care, and poor appetite.
  • Past Psychiatric History: History of insomnia, treated with Haldol.
  • Medical History: Diabetes mellitus, shoulder pain.
  • Social History: Lives alone with a dog, limited social support.

Objective Data:

  • Physical Exam: Unkempt appearance, poor hygiene, and signs of malnutrition.
  • Mental Status Exam: Confused, disoriented, poor insight, and impaired judgment.
  • Laboratory Findings: Elevated blood glucose levels.