Major Case Analysis

Running head: CLINICAL CASE STUDY

CLINICAL CASE STUDY

Author's Name

Institutional Affiliation

CLINICAL CASE STUDY

ChiefComplaint: 

IjustmovedherefromGAandIneedtohavepsychiatriccareandmymedication

HistoryofPresentIllness:(includingbaselineandifcurrentsymptomsaredifferentfrombaseline)

Hispanicfemalewithlongtermhistoryofbipolardisorderwithcurrentuseofhighdosesofalprazolam

daily.Presentstovisitmostlyanxiousandelevatedwithpoorsleepcontrolandagitatedrenot

yesterday.Spokeatlengthreconditionandpoormaniccontrollackofmedicationformaniapreviously

previouslyusedlithiumanddepakotewithpoorresults,andcurrentlyonlowdoseseroquelbut

reportsirritabilityandhistoryofangerandimpulsivitywithmultiplehospitalizations.Patient

eforsce.andconsistentwithreportedtreatment.Patientwithhistoryofseizuress/pwithdrawal

PastPsychiatricHistory: Ye

Outpatient:

Patientwithsymptomsofbipolar1disorderattheageof22,whilelivinginArizona

Inpatient:

Multipleinpatientadmissions.

LastadmissioninAtlanta,GA31/2yearsago

AlcoholorDrugs:

Marijuanausecurrentonlyvapes.

Seizure/TBI/ECT:

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seizurer/ttowelbutrinRXandwithbenzodiazepinewithdrawal

Suicidal/HomicidalHistory:

Multipleattempts,morethan5times,onlycuttingwrist.

Medications:

Vyvanse60mgPOQD

alprazolam2mgPOTID

quetiapine400mgPOBID

Gabapentin300mgPOQHS

MedicalHistory:

Nochronicconditions

Onlymedicationformentalhealthissues.

RxAllergies:

NKDA

FamilyPsychiatric/MedicalHistory: Yes IfYes,describe:

Motherandmaternalgrandmotherwithpsychoticfeatures.

BrotherwithMDDcommittedsuicide

PsychosocialHistory:

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Born:

BorninArecibo,PR



Raised: 

Raisedbybothparents 

LivingSituation:

Liveswithsonwithdifficultathomedynamic

Childhood:

1/4siblings,goodchildhood

Education:

BAEducation

Workedineducation2012

Abuse:

denies

Employment:

denies

Parents:

Motheralive

Fatherdiedofrenalfailureat82y.o.

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Children:

2sons

LegalProblems:

Nolegalentangelments

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Chief Complaint

"I just moved here from Orlando, and I need to have psychiatric care and my medication."

HISTORY OF PRESENT ILLNESS (HPI)

Ms. D is a 22-year old Hispanic female with ongoing symptoms of the long-term history of

bipolar one disorder. Ms. D is a resident of Arizona and has had several inpatient admissions,

with the last one being in Atlanta, GA, 3 1/2 years ago. The patient is accompanied today by her

mother, who is also the caregiver. Ms. D reveals that she uses marijuana only by paving. In the

last ten days, Ms. D's condition had exacerbated to the manic episode as she exhibited some

extreme symptoms, including suicidal behavior. From the record and her caregiver's testimony,

Ms. D has cut her wrist in an attempt to commit suicide more than five times. Both her arms

reveal several marks of cuts, one of them looks fresh.

From the conversation with both the patient and her caregiver, she has had a good childhood

with caring and responsible parents. The patient was brought in a nurturing and safe community.

The mother states that the patient has no history of violence or verbal abuse. She was raised in a

Protestant home and is a regular churchgoer. Mother reveals that prior to her mental condition,

Ms. D committedly participated in volunteer and church study groups. She describes her

religiosity as "fairly reasonable" and has never shown any form of religious paranoia or

delusions until three weeks ago when she began to act and talk strangely. "Demons are watching

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and following every time. They are talking loudly in my head. They have threatened to punish

me I do anything they don't like. How are you not seeing them, yet they are every corner of the

house?" Ms. D suddenly intervenes with a loud voice.

The most recent episode was Ms. D harming herself by inflicting cuts on her wrists. Mother

reveals the patient does this, and she terms it as "cutting off links with demons." In total, the

patient has attempted suicide five times over the last four week, and each of these attempts has

involved cutting her wrists with sharp objects. When questioned about her self-harming

behavior, Ms. D reveals she was "pushed by the bad people" who have made her life unbearable.

Past Psychiatric History

Ms. D does have a history of psychiatric conditions. The patient reports irritability and a history

of anger and impulsivity with multiple hospitalizations. The patient had marks on her arms

resulting from her previous suicide/self-harm attempt. Medical history revealed that Ms. D had

sustained a head injury in 2005 after falling from the staircase. He had been successfully treated

with damage and no other incident of a major injury since then. The mother reveals that Ms. D

had a troubled sleep problem as she slept very little, spending the rest of the day looking very

energetic. However, she was occasionally very moody and irritable. The mother reveals she says

people talking around irritates her, and she would often prefer staying alone in her bedroom.

Moreover, the other reveals that Ms. D's condition was causing her problems in school. She

complained about being easily distractible and a severe inability to concentrate. As a result, her

academic performance in college had dwindled significantly. In the last three days, the mother

reveals, Ms. D started to exhibit strange symptoms. Other than strange delusions, the patient also

complained about hearing loud and "scary" voices in her head, calling her to visit "hell."

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Previously on Gabapentin but not taking, previously used lithium and Depakote with poor

results, and currently on low dose Seroquel but without medication at this time. Patient

information verified with prior MD and consistent with reported treatment. Patient with history

of seizures s/p withdrawal of benzodiazepines and with Welbutrin.

Substance use history

When asked about her drug/substance use, the patient says she only uses the "healthy and sweet"

marijuana, but she only vapes it. She had used marijuana since the age of 15. She rarely used

marijuana in the past, but in the last few months, she is using it on a daily basis and in greater

quantities. The patient denies any other illicit drug use.

Past medical surgical history

Ms. D has not had surgeries in the past. Medical history revealed that Ms. D had suffered a head

injury in 2005 after falling from the staircase. The injury was successfully treated but without

any surgery. Patient denies any other major injury.

Current Medications

Vyvanse 60 mg PO QD

alprazolam 2 mg PO TID

quetiapine 400 mg PO BID

Gabapentin 300 mg PO QHS

Rx Allergies

NKDA

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Family Psychiatric History

There was a significant family history of psychiatric/neurological illnesses, but her premorbid

personality did not have any hyperthymic traits. Both Ms. Ds mother and grandmother had a

history of psychotic illnesses. In addition, her brother had suffered Major Depressive Disorder

(MDD), which led to him committing suicide five years ago. Mother denies any other case of

psychiatry problem. No adequate knowledge of grandparents. No history of child adoption in the

family.

Social History

Ms. D was born in Arecibo, Puerto Rico, but the family moved to Orlando, Florida. Family

history reveals that the patient reveals her father died of renal failure ten years ago at the age of

59 years of age. Mother is 57 years old and in good health. The patient is the first of four siblings

(two sisters and one brother, who committed suicide five years ago. Both sisters have no history

of any mental/psychiatric problem. She lives with her family in a double dwelling 3 storey

home on 6 acres in Atlanta. No industrial plant is near or within the neighborhood. She has one

cat pet.

Ms. D has two children (two sons). None of the children has a history of any psychiatric or

mental problem. However, she was widowed three years ago and has been the sole provider for

her two sons. However, the mother reveals she has been unemployed for long, and her financial

situation has been difficult for the last three years. According to her, she has never had any legal

entanglements in her life. Ms. D denies having any marital /relationship problems with her late

husband. Denies any history of sexual abuse.

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Ms. D has a bachelor's degree in education, having graduated in 2017. To the best of her

knowledge, Ms. D says she had a "normal" school life with many friends and good academic

performance. She has never had major problems in school and got along well with both

classmates and teachers.

REVIEW OF SYSTEMS

General: Reports hearing loud voices in her head in the last three days. She thinks this emanates

from her marijuana use. Mother reveals it is the first time she had exhibited extreme symptoms

and fears she might be losing her mind.

Neurological: Unsure about having any altered level of consciousness. Loud and irritating voices

in the mind. Voices calling her to visit hell. She says this experience is scary and makes her

easily irritable. Ms. D says the loud voices make it very difficult for her to concentrate on

activities. She also reports loss of appetite in recent weeks, which has made lose about 4 pounds

in the last month. Denies any transient paralysis seizures. Denies any tremors and vertigo.

HEENT: Denies headache. No changes in vision. Denies any sore throat. Positive for hearing

loss. Last dental exam is not known.

Neck and Lymphatics: No lumps or swollen glands, goiter. Positive for thyroid enlargement/

pain.

Chest and Lungs: No chest pain. Positive for palpitating, No diaphoresis, or claudication.

Denies, cough, hemoptysis, asthma, bronchitis, pneumonia, or tuberculosis.

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Cardiac: Positive for hypertension. No cardiac related problem. Denies cardiac murmurs. No

history of rheumatic fever, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, chest

pain, or palpitations.

Gastrointestinal: Patient denies jaundice

Musculoskeletal: patient denies muscle cramps, back pain, and joint paint. Past injury on head.

Denies weakness and stiffness.

Skin, Hair, Nails: denies rash, denies any dryness, lumps, color changes and suspicious lesions.

Genitourinary: Denies any Denies infections, discomfort or urinary frequency.

Hematologic: denies any bruising, bleeding, or lymph nodes abnormalities.

Endocrine: denies thyroid problems cold intolerance, heat/temperature intolerance, diabetes

polyphagia or polyuria.

PHYSICAL EXAMINATION

General: Weight=150 lbs, Height= 5'5 BMI=24.96

Vital signs: Blood pressure 131/98, heart rate 71, and respiratory rate 17.

MENTAL STATUS AND ASSESSMENT

Ms. D is a 22-year old Hispanic female with m symptoms of the long-term history of bipolar one

disorder. She looks normal, well dressed, and neatly kempt short hair. At times, the patient

appears calm but then suddenly becomes overly talkative, shifting from one issue to another.

Patient has no odor. When questioned about her marijuana use, she becomes argumentative and

noticeably irritable. Most of the emotions demonstrated during the engagement with Ms. D was

CLINICAL CASE STUDY

irritability. She often raises her voice in disagreement when her mother tries to the narrative

some of the strange events and behaviors she had exhibited. For instance, she vehemently

denied self-harming herself and instead claims the marks on her hands came from a small

accident she had. However, she suddenly corrects her statement and says she inflicted the

injuries in an attempt to "cut links with demons." After this, she goes completely quiet and

seems to have lost interest in the interview.

The patient's speech was clear and sometimes articulate, firmly denying any sort of the alleged

hallucinations reported by the mother. On the MMSE (mini-mental state examination), the

patient's total score was 24. Her appetite was unusually low, and she blamed the "people" inside

her head for constantly annoying her and making her lose interest in food. She made several

errors in reading, attention, and writing. However, she expressed sexual interest, occasionally

saying, "I will marry all the good doctors in the hospital." Ms. D admits she has an anger

problem. She reports extreme irritability when confronted. She exhibited anger and frustrated

facial expressions throughout the interview, especially when asked questions.

Marijuana use is known to cause symptoms of bipolar 1 disorder and other mental problems.

Marijuana-induced bipolar disorder is a rare occurrence, and it is often not clear whether the

problem emanates from the drug or the patient has an underlying untreated bipolar disorder.

"Clinicians agree that cannabis use can cause acute adverse mental effects that mimic psychiatric

disorders, such as schizophrenia and bipolar disorder. Although there is good evidence to support

this, the connections are complex and not fully understood" Khan & Akella (2009).

Laboratory Data

CLINICAL CASE STUDY

The patient has not had any lab test in recent times. The last lab tests were done three years ago. I

would recommend Functional magnetic resonance imaging or functional MRI (fMRI) study to

examine the patient's ventrolateral prefrontal emotional arousal network.

Psychiatric Summary

Ms. D Ms. D is a 22-year old Hispanic female that is educated to college level. The patient is

suffering from delusions, hallucinations, insomnia, irritability, insomnia, anger, and suicidal

thoughts/behavior. The patient has attempted suicide five times in the last one month. She uses

marijuana on a daily basis and in large quantities. She has increasingly become paranoid about

voices in her head. As a result, the family is becoming concerned about that she is exhibiting

strange behaviors. Her symptoms are worsening, and she has many wrist cuttings. Ms. D does

recall her past life but denies any delusions, hallucinations, and strange behavior. She is easily

distracted and irritable.

Diagnosis

DSM-5 296.43 296.42 Bipolar I Disorder, current episode manic, moderate severity, with

mixed features

2020 ICD-10-CM Diagnosis Code F12.93 Cannabis use, unspecified with withdrawal

History of head injury in 2005

Marijuana use

The Diagnostic and Statistical Manual of Mental Disorders, Fifth EditionDSM-5 (formerly

known as DSM-IV TR) is the principal authority for diagnosis of psychiatric problems. It was

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developed by the American Psychiatric Association and is the diagnostic tool utilized in

psychiatry.

PLAN

Safety

As revealed earlier, the patient has exhibited self-harming behavior in the last three days. Her

manic episode prevents making rational decisions hence the need for a safety plan to enable her

and caregivers to manage the bipolar crisis. We discussed with the mother about closely

monitoring and documenting her strange behaviors. Also, we talked about Ms. D's not being left

alone in the house and the need to put away all sharp objects and anything that she can

potentially use to harm herself.

In the words of Jones et al., "People with BD are at high risk of engaging in suicidal behaviors

(i.e., suicide and self-harm) and the risk of suicide and self-harm is high in those with BD."

Rapid access to care is vital in responding to self-harming /suicidal behaviors. Also, patients, as

well as caregivers, should be made more aware of the available service. More importantly, closer

involvement of caregivers is vital to ensure quick and effective response before the patient

inflicts lethal harm on themselves.

Substance Abuse

We held a discussion with the mother about the need to eliminate all possible ways for the

patient getting marijuana. We discussed the need to consider moving to a new location where

she cannot access marijuana and free from peer influence. Limit her cell phone usage and talk to

all relatives, neighbors, and friends about the patient's health risks.

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Medications

I reviewed her medications with both the patient and her mother, and she agreed to continue with

the same dose of Vyvanse 60 mg PO. Alprazolam 2 mg PO TID. However, I would increase the

Quetiapine at 100 mg QAM and 400 mg QHS day to stabilize the manic symptoms. Also, I

would stop the Gabapentin due to the risk of causing depression and suicidality. Also, I would

start with Lamictal 25 mg PO QHS per day, an anti-epileptic medication, and anticonvulsant

used in the treatment of epilepsy and bipolar disorder. Lamictal will be used to stabilize the

patient's mood and to relieve her mania and mood swings.

According to WebMD (2019), "Lamotrigine is known as an anticonvulsant or antiepileptic drug.

It is thought to work by restoring the balance of certain natural substances in the brain."

Diagnostic Studies

I would use electrocardiogram (ECG/ EKG) to distinguish between bipolar disorder from major

depressive disorder. This is important to ensure avoid misdiagnosis, increase accuracy of

diagnosis and treatment of Mr. D’s mental problem.

“Bipolar disorder is commonly misdiagnosed as major depression, which can be detrimental to

the patient, since treatment plans for the disorders are very different. A simple 15-minute

electrocardiogram (ECG or EKG) can help determine whether a patient has major depression or

bipolar disorder” (Medscape, 2017)

Education

We discussed at length about the importance of sleep and comfort for Ms. D. I directed the

patient's mother to consult her nearest care provider to learn about some of the vital tips for

CLINICAL CASE STUDY

managing bipolar one patient's symptoms and crises. In addition, we discussed some of the

everyday healthy living strategies. For instance, we extensively discussed setting a schedule,

paying attention to the patient's sleeping patterns, exercise, and, more importantly, the need to

keep the patient away from marijuana and any other substance. I directed Ms. D and her

caregiver to the facility's resident nutritionist to briefly educate them on the right kind of foods

that can help her feel better.

According to WebMD (2019), rather than social media and television, bipolar patients should

"try something more focused, like yoga or other types of exercise. Meditation is another good

choice. An easy way to do that is to focus on your breathing for a few minutes, letting other

thoughts come and go without paying them a lot of attention."

Support System

We discussed the need to offer the patient the much-needed emotional, social, psychological, and

even financial support in order to improve her recovery process. We discussed various ways in

which family could support the patient. These include listening, encouraging, spending time

together, and, more importantly, being a partner in treatment. Further, we discussed in length the

need to closely monitor her progress and any other strength symptoms.

According to Mansfield et al. (2012), "family-based psychoeducation is effective in reducing

relapse of manic symptoms, while family-based psychotherapeutic interventions are more

effective in reducing relapse of depressive symptoms. More studies are needed to determine

which types of intervention are most effective."

Therapy

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After a lengthy discussion with Ms. D, she has agreed to enroll in psychotherapy sessions. Two

major types of therapy were preferred for the patient; Cognitive behavioral therapy (CBT) and

Family-focused therapy.

According to Mayo Clinic (2019), while CBP focusses on identifying unhealthy, adverse

beliefs/thoughts and behaviors and replacing them with healthy, positive ones, Family-focused

therapy helps the patient to stick with his or her treatment plan. It also helps both the patient and

loved ones to recognize better and manage warning symptoms of irritability, aggression, and

other mood swings.

Monitoring

Safety monitoring of the patient’s medicines during therapy will be done at each visit.

Monitoring will be carried out in accordance with International Society for Bipolar Disorders

(ISBD) guidelines. Treatment adherence of the patients will be monitored at each visit. Ms. D’s

current depressive symptoms will be monitored an assessed using tools such as the 9-item Patient

Health Questionnaire and the Beck Depression Inventory.

To optimize treatment in bipolar patients, care providers need to closely monitor psychiatric,

medical outcomes and medication adherence of the patient. Psychiatric symptoms that need

assessment and monitoring are both those with primary psychiatric disorder as well as those

common psychiatric comorbidities including substance use disorders, stress and anxiety (Ketter,

2010).

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References

Jones, S., Riste, L., Barrowclough, C., Bartlett, P., Clements, C., Davies, L. & Morriss, R.

(2018). Reducing relapse and suicide in bipolar disorder: practical clinical approaches to

identifying risk, reducing harm, and engaging service users in planning and delivery of

care–the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation,

and Suicidality) program.

Ketter, T. A. (2010). Strategies for monitoring outcomes in patients with bipolar

disorder.Primary care companion to the Journal of clinical psychiatry,12(Suppl 1), 10.

Khan, M. A., & Akella, S. (2009). Cannabis-induced bipolar disorder with psychotic features: a

case report. Psychiatry (Edgmont), 6(12), 44.

Mansfield, A. K., Dealy, J. A., & Keitner, G. I. (2012). Family interventions for bipolar disorder:

a review of the literature. Neuropsychiatry, 2(3), 231.

Sahu, K. K. (2013). Family Intervention with a Case of Bipolar I Disorder with Family Conflict.

Online Submission, 4(2), 165-171.

Soreff, S. (2019). What is included in the Mental Status Exam for bipolar affective disorder

(manic-depressive illness)?. Medscape. Retrieved from

https://www.medscape.com/answers/286342-101500/what-is-included-in-the-mental-

status-exam-for-bipolar-affective-disorder-manic-depressive-illness

WebMD (2019). 12 Ways to Help Someone With Bipolar Disorder. Retrieved from

https://www.webmd.com/bipolar-disorder/bipolar-life-17/slideshow-help-someone-with-

bipolar

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WebMD (2019). Everyday Tips for Living With Bipolar Disorder. Retrieved from

https://www.webmd.com/bipolar-disorder/guide/living-healthy-life-with-bipolar#1

WebMD (2019). Lamictal Tablet. Retrieved from https://www.webmd.com/drugs/2/drug-8486-

7217/lamictal-oral/lamotrigine-oral/details

WebMD (2019). Olanzapine. Retrieved from https://www.webmd.com/drugs/2/drug-1644-

9274/olanzapine-oral/olanzapine-oral/details

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