CLINICAL CASE
PRESENTATION
Ka’lesha Jones
Wilkes University
NSG 536 Adv Practice in Psych/MH Nursing II
IDENTIFYING INFORMATION
▪ E.R. 34-year-old Hispanic female.
▪ Evaluated at the bedside on 7-9-21.
▪ E.R. a reliable historian is the primary source of information. Pt girlfriend at
the bedside for collateral information.
▪ Psychiatric consultation requested for sudden onset of increased agitation and
change in behavior.
CHIEF COMPLAINT
▪ “I received a video message on Tik Tok with a bunch of my family members
saying they wish I would die in the hospital, and I got very upset. I have not
been on my medication, so I exploded.”
HISTORY OF PRESENT ILLNESS
▪ Presented to the hospital with migraines and sudden onset of right-sided weakness. Received upsetting video
message posted on social media and became agitated, screaming, making verbal threats against family
members, called police several times. Unable to redirect. Haldol 2 mg and Ativan 1 mg given IM.
▪ Hx of mental illness, has not been on psychotropic medications for three months due to lack of insurance.
▪ Complains of night terrors, poor appetite, insomnia/hypersomnia, anhedonia, fatigue, increased agitation,
irritability, anxiety, and depression for the last four months. 17lb weight loss in one month.
▪ Endorses visual hallucinations. Sees figure of ex-fiancé around home.
▪ Engaging in self-harm behaviors such as cutting wrists and thighs with razor blades. Restarted 2 months ago.
▪ Passive suicidal ideation. Denies plan or intent.
▪ Indicates when medicated mood symptoms were less severe and labile. No self-harm behaviors. No
hallucinations or delusions noted.
REVIEW OF SYSTEMS
▪ Constitutional: Negative.
▪ Endocrine: Negative.
▪ Eye: Negative.
▪ Immunologic: Negative.
▪ Ear/Nose/Mouth/Throat: Negative.
▪ Musculoskeletal: Right-sided
weakness started 2 days ago
▪ Respiratory: Negative.
▪ Cardiovascular: Negative.
▪ Gastrointestinal: Negative.
▪ Genitourinary: Negative.
▪ Gynecologic: Negative.
▪ Hematology/Lymphatics: Negative.
▪ Integumentary: Negative.
▪ Neurologic: Migraines, diffuse with
aura.
PAST MEDICAL HISTORY
▪ Medical History
▪ Allergies:
▪ Ibuprofen (SOB; urticaria)
▪ Latex (rash)
▪ Migraine headaches
▪ Asthma
▪ Arthritis
▪ Surgical History
▪ Hysterectomy
PAST PSYCHIATRIC HISTORY
▪ Anxiety diagnosed age 13.
▪ Depression diagnosed age 15.
▪ Bipolar disorder diagnosed age 21.
▪ Seven previous inpatient psychiatric hospitalizations. Last hospitalized in 2018 for acute mania.
▪ Four previous suicide attempts – overdose, cutting wrist. Last attempt 2016.
▪ Outpatient substance rehabilitation program x 2 years.
▪ Outpatient counseling starting at age13. Last seen three months ago.
▪ Trial medications of Trazodone and Seroquel.
▪ Last prescribed Geodon 20 mg b.i.d, Klonopin 1mg t.i.d. as needed, Zoloft 10 mg daily, Minipress unknown dose
q day with good response.
FAMILY HISTORY
▪ Medical History
▪ Cancer
▪ Father/Grandfather
▪ Hypertension
▪ Father, Mother, and Grandmother
▪ Psychiatric History
▪ Anxiety
▪ Depression
▪ Bipolar disorder
▪ Alcoholism
▪ Polysubstance Abuse
▪ Multiple suicide attempts and selfharm behaviors by various immediate
family members. [2 completed by 1st
cousin and brother].
DEVELOPMENTAL/PSYCHOSOCIAL HISTORY
▪ Born in Harlem, New York. Raised by single mother. Poor relationship with father.
▪ One of eleven children. Youngest on her mother's side.
▪ History of sexual molestation by a male and female cousin between age 8-10.
▪ Poor self-esteem, impulsive and self-harming behavior, sexual promiscuity.
▪ Physical and emotional abuse in last relationship of nine years.
▪ Highschool graduate. Currently employed as a line cook at Outback Steakhouse.
▪ Moved to Florida three months ago from PA. Resides with significant other.
▪ Three children with ex fiancé who reside with their father [court order].
▪ Denies social support. She is in contact with her mother but has a tumultuous relationship with siblings and
ex-fiancé.
▪ Several pending and prior legal issues.
SUBSTANCE USE HISTORY
▪ Alcohol – (13) History of alcohol
abuse.
▪ Current use: Wine, Beer.
▪ 2-3 glasses a month.
▪ Nicotine – (15) “I’m trying to cut
down.”
▪ Current use: 1 pack per month.
▪ Illicit substance use – to manage
“anxiety, appetite, and insomnia.”
▪ Marijuana and THC products (19)
(gummies)
▪ Current use: 2-3x/daily
▪ MDMA (19)
▪ Past use: “I tried it 4 or 5 times.”
▪ Denies any other illicit substance use.
Denies abuse of prescription drugs.
MENTAL STATUS EXAMINATION
• General appearance: Appears stated age.
Appropriately groomed. Appr. 2-4 in. lacerations
bilateral wrist and forearms.
• Speech: Clear, coherent.
•
Homicidal: “I did say I wanted to kill them, but I would
never.”
• Orientation: Alert and oriented to person, place, time,
and situation
• Mood/Affect: Anxious, tearful. Congruent; full range. • Judgement: Fair
• Thought content: guilt, worthlessness, excessive
worry.
•
Hallucinations: Sees ex-fiance standing menacingly
around the home.
•
Delusions: Possible delusional phenomena noted
further investigation necessary.
•
Suicidal: Passive SI. No plan or intent.
• Memory: Recent and remote memory intact.
• Attention and concentration: Fair
• Language: Good
• Fund of knowledge: average
• Impulse control: Adequate
SCREENING SCORES
MMSE:
30/30
PHQ-9:
24/27
GAD-7:
21/21
DIFFERENTIAL DIAGNOSIS
▪ Schizoaffective disorder, bipolar type
▪ Rule out : Borderline Personality disorder
DIAGNOSTIC IMPRESSION
▪ Bipolar disorder, current episode depressed with mood congruent psychotic
features
▪ History of mania and depression.
▪ History of delusional and hallucinatory phenomena associated with mood symptoms.
▪ Current presentation: depressed mood, anhedonia, agitation, irritability, fatigue, +
visual hallucinations and possible delusions.
▪ Anxiety Disorder, unspecified
▪ History of anxiety disorder.
▪ Scored a 21 on GAD
NEUROBIOLOGY
▪ Bipolar Disorder
▪ Interacting genetic, environmental, biological, and psychosocial factors result in neuronal changes
and modified brain circuitry (Vieta et al., 2018).
▪ Symptoms result from dysfunction in the interaction of prefrontal-subcortical networks within the
limbic structures (amygdala, anterior cingulate cortex, and insula) (Stovall, 2020).
▪ Possible abnormalities of neurotransmitters involved in modulating emotions: serotonin,
norepinephrine, and dopamine (Perese, 2012).
▪ Anxiety Disorder, unspecified
▪ Abnormalities in occipital lobe, basal ganglia, limbic system, hippocampus, brainstem, and frontal
cortex (Perese, 2012).
▪ Neurotransmitters involved in fear/anxiety
▪ ↓ serotonin 5-HTa binding, ↓ GABA functioning
RECOMMENDATION/PLAN
▪ 34-year-old who was admitted to this facility via emergency services for onset
of right-sided weakness and migraines. Patient with onset of increased
agitation and change in mood during hospitalization. At this time given
patient current presentation recommend initiating voluntary Baker act and
restart Geodon 20 mg b.i.d. Zoloft 10 mg qday. Continue Klonopin 1 mg t.i.d.
PRN while inpatient.
▪ Consider transfer to Baker Act receiving facility once medically cleared.
▪ Discussed with patient community resources for follow-up care since some she
has been living here for the past 3 months a needs to be linked with
community resources.
PATIENT EDUCATION
▪ Treatment options
▪ Baker Act law
▪ Initiation of Baker Act
▪ Risk and benefit of Geodon;
adding/switching to Lamictal or
Zyprexa
▪ Risk and benefits of Zoloft
▪ Inducing mania
▪ Outpatient cognitive-behavioral therapy
▪ Psychosocial interventions
▪ Reinforced education on bipolar
disorder
▪ Signs and symptoms
▪ Suicide risk
▪ Course of illness
▪ Stress management
▪ Treatment adherence
▪ Relapse prevention
▪ Coping skills
▪ Social support
▪ Reviewed emergency procedures and
safety plan with patient.
REFERENCES
Perese, E. (2012). Psychiatric advanced practice nursing: A biopsychosocial foundation for
practice (1st ed.). F. A. Davis Company.
Stovall, J. (2020). Bipolar disorder in adults: Epidemiology and pathogenesis (P. Keck & D.
Solomon, Eds.). UpToDate. Retrieved July 18, 2021, from
https:/ / www.uptodate.com/ contents/ bipolar-disorder-in-adults-epidemiology-andpathogenesis
Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., Gao, K.,
Miskowiak, K. W., & Grande, I. (2018). Bipolar disorders. Nature Reviews Disease
Primers, 4(1). https:/ / doi.org/ 10.1038/ nrdp.2018.8