Grand Rounds Discussion: Complex Case Study Presentation

PATIENT CASE STUDY

Subjective

The patient is a 12-year-old female that is brought in for an initial evaluation by her mother with consent obtained via telehealth. The patient's mother stated that the patient was admitted to Brook Lane inpatient 2 weeks ago for suicidal ideations; she had previously been diagnosed with ADHD and was on Vyvanse and Prozac which they said exacerbated the mood disorder. The mother said that she was properly diagnosed at Brook Lane and was prescribed Lamictal 25mg from the inpatient admission starting on 5/26/22. She has side effects of nausea, but I do feel like she is doing better, she is calmer but before she was restlessness and impulsivity". The patient stated, "I tried to kill myself by cutting and overdosed on Ibuprofen. I don't know how I felt when I was doing it".

Objective:

The patient is alert and oriented x 4, to person, place, and time, and aware of the situation. She presented herself very well. The general appearance is neat and clean, with normal eye contact. Her psychomotor activity is normal with intact attention, though she looks tired and agitated. Her speech is normal, and mood is irritable, and her affect is congruent to her mood. The thought process is linear and gold-directed and thought content is intact. Her perception is fair, insight fair, and cognition is intact. The patient denied suicidal or homicidal ideation presently. She also denies delusions or hallucinations presently.

Assessment

The patient is brought in for an initial evaluation by her mother. The patient is reserved during the interview, and short with her responses. Her mother explains that the patient was previously admitted to an inpatient psychiatric unit for a suicide attempt. In that hospitalization, the patient was diagnosed with a mood disorder and started on Lamictal 25mg. Her mother reports an observable change in her mood, but a side effect of nausea. The PHQ is used, and the patient scored patient scores 17/27. She is currently in therapy and has reportedly established trust with her therapist. She will continue therapy sessions. She will continue taking Lamictal 25mg daily to improve her mood. She will start taking Omega 3 fish oil 300mg daily to aid her cognition and recall. She is educated on medication side effect and interactions; reassured that nausea will subside as the week progress. The patient and mother are encouraged to keep a journal of her high and low moods to discuss during her next follow-up visit. She is educated on positive coping mechanisms to improve her mood. She verbalizes understanding.

Plan of care:

The patient will have an improved mood within the next 90 days.

The patient will continue Lamictal 25mg daily to help with her mood.

The patient will start Omega 3 fish oils 300mg daily.

The patient will continue psychotherapy sessions.

The patient is educated on medication side effects and interactions.

The patient is encouraged to keep journals of high and low moods and bring it to the next follow-up visit for discussion.

The patient is educated on positive coping mechanisms to improve her mood.

Follow up in 4 weeks.

Call 911 for suicidal or homicidal ideations.

Here are the VITAL SIGNS Below:

B/P=113/62, temperature=97.9, Pulse=78, Respiration=18, Oxygen=98%, Weight=101lbs.