SAMPLE
LUCILE PACKARD CHILDREN'S HOSPITAL
CONSULTATION - MNEMONIC: MRCON
INPATIENT CONSULTATION = WORK TYPE 2
OUTPATIENT CONSULTATION = WORK TYPE 3
SAME FORMAT AND MNEMONIC FOR BOTH.
_________________________________________________
CONSULTING PHYSICIAN:
DATE OF CONSULTATION:
Michelle Brown, Ph.D.
12/01/2003
REASON FOR CONSULTATION: We were asked to see this patient to investigate
psychiatric reasons for her noncompliance. This history was obtained by
speaking to the patient alone. We could not contact the mother at the time.
HISTORY OF PRESENT ILLNESS: Jane Doe is a 15-year-old Caucasian female with a
two-year history of diabetes mellitus type 1 who was admitted Friday,
11/28/2003 in diabetic ketoacidosis. This is the second time that she has
been hospitalized for this condition. The first time was two years ago and
that was when her diagnosis of diabetes mellitus was made. Today, Monday,
12/1/2003, the patient does not know why she has been hospitalized. She
relates feeling "sick" the day of her hospitalization and vomiting copiously.
She also states that her mother described unusual behavior such as Jane
getting under the table that day and speaking nonsensically. The last event
she remembers was getting into her mother's bed and continuing to throw up.
She was brought into the hospital kicking and screaming and semi-conscious.
Her blood sugar level was found to be 364.
Jane has been self-administering insulin since the time of diagnosis. She has
never been fully compliant, however. Initially, her mother supervised her
very closely. After two months of this, Jane became very irritated with her
mother and asked that she be allowed to administer her insulin alone without
her mother's presence, which she saw as intrusive. A short while later, after
attending a camp in which she neglected her diabetic treatment in favor of
less boring activities, Jane found her mother "pissed off". Apparently, her
mom had looked at her monitor and reviewed her blood sugar values shortly
after Jane returned home from camp and deduced that she had been noncompliant.
A short period of close supervision followed. Then her mom relaxed her vigil
and Jane had another lapse of compliance. This pattern characterizes the
majority of Jane's diabetic career. Two months ago, Jane went to clinic and
her hemoglobin A1c was found to be 14. Jane appreciates the gravity of this.
So did her mother ostensibly, because soon after, according to Jane, her
mother took a more active role in her treatment. Rather than periodically
look over Jane's shoulder at the monitor, mom helped Jane calculate how much
insulin was needed based on the amount of food consumed and helped Jane
administer the insulin. Jane claims that her mother's increased role and more
intimate supervision have assisted her in becoming more compliant. She claims
that her blood sugar levels have been fairly stable for the past two months,
generally falling anywhere between 100 and 200.
Jane is well informed about the pathogenesis of diabetes. She also
understands why treatment is necessary and the consequence of noncompliance.
Her understanding, in fact, sometimes exceeds that of someone her age as in
her detailed knowledge of hemoglobin A1c and its clinical significance. Jane
attributes her noncompliance to "having better things to do", suggesting that
treatment sometimes interferes with other activities she would much rather do.
She also disclosed an episode that happened during a period in which her
mother supervised her. She would get the monitor out as her mother watched
from a distance and go through the motions of testing herself without doing so
in actuality in order to appease her mother. This suggests that Jane is
noncompliant for more than the simple reason that the treatment is
inconvenient for her. It may also be part of a complex relationship with her
mother.
In the past two months, Jane has experienced a drop in grades, which she says
is typical for her around this time. She has also become less involved in
Internet column writing, a hobby which she previously enjoyed and which is
important to her as an aspiring journalist. She has also become less
interested in soccer. She attributes this to being unhappy with the coach and
the rest of the team, which she dislikes. She has not suffered from a drop in
mood or a change in sleep or dietary habits. She does not complain of
suicidal ideation, guilt, hopelessness or helplessness. At this time, Jane is
eager to leave the hospital. She does not care to find out what happened to
her. She simply wants to leave.
Jane has no previous psychiatric history.
abuse.
She denies any history of substance
PAST MEDICAL HISTORY: Significant for diabetes mellitus type 1, diagnosed two
years ago, and one previous episode of diabetic ketoacidosis at the time of
diagnosis. She has never been hospitalized for other reasons nor has she ever
had surgery.
MEDICATIONS:
times a day.
She is on NPH, lispro and glargine.
She takes insulin four
PERSONAL HISTORY: The patient was born in Woodside. Her parents divorced
when she was eight months. Her father moved to San Jose and she continued to
see him when she liked, primarily on the weekends. She lives with her mother
and has lived with her mother since the divorce. Her mother owns a gallery in
Woodside. She describes her relationship with her mother as "okay". She
claims that her mother has some good qualities and some bad qualities. Good
qualities include being modern and knowing how to have fun. Bad qualities
include being frantic, hurried and always having something to do. She
describes her relationship with her father as good. She visits him
occasionally but does not know what type of work he does. She claims that her
father goes from one relationship to another with a bunch of "creepy women".
She claims that her relationship with her half-sister who is five years old is
half strained. The sister lives with her dad. She is currently a sophomore
in high school. She claims that her school performance is "okay". She
maintains a C average. Her school performance is characterized by a drop in
grades halfway through the year, which return to passing with effort and work
by the end of the year. She claims this pattern has always been part of her
academic performance. She says that she has many friends at school and enjoys
going.
MENTAL STATUS EXAMINATION: The patient was interviewed while supine on her
bed, dressed in pajamas and appearing apathetic and sleepy. She is pleasant
and communicative. She demonstrates no unusual mannerisms. She describes her
mood as "okay" and her affect is generally bland. She occasionally smiles,
pouts to indicate boredom or impatience or grimaces. She answers questions
appropriately, though she is not elaborative and is often monosyllabic.
Sometimes she is quite articulate and demonstrates a good vocabulary. Her
thought processes are goal directed without looseness of association or flight
of ideas. She denies any psychotic symptoms including hallucinations,
delusions, paranoia or megalomania. She denies suicidal ideation. She is
eager to leave the hospital but does not know the precise reason why she is
here, nor does she care to know. She denies hopelessness or helplessness.
Her insight is poor but her judgment could not be ascertained. It has been
demonstrably low in the past with her history of noncompliance.
FORMULATION: The patient has been generally noncompliant since her diagnosis
two years ago. The reason for this is multifactorial. The patient seems to
be knowledgeable about her disease and appears cognizant of the consequences
if it is untreated. So, her total ignorance regarding this hospitalization is
very incongruent and strange. She may benefit from diabetic education in case
some aspects of her disease are, in fact, mysterious to her. She is also on a
very labor-intensive insulin regimen four times a day. Since she says her
noncompliance is due to "having better things to do", perhaps she will benefit
from an insulin schedule that interferes less with her life and to which
adherence is easier such as two times a day. Jane also admits that her
mother's active involvement, while sometimes bothersome, increases her
compliance so implementing a plan that involves the mother, as the pivotal
part of treatment may be helpful. Behavior modification will also be helpful
for the same reason that setting limits appears to be. The past few months
have involved loss of interest in many activities, both school and otherwise,
alongside the probably severe noncompliance. While the patient does not
endorse other symptoms suggestive of depression, it is worthwhile
investigating her for a mood disorder, which may or may not be related to her
diabetes. The family dynamic merits exploration, as well, and may further
elucidate her noncompliance.
DIAGNOSIS:
AXIS I:
AXIS II:
AXIS III:
AXIS IV:
AXIS V:
Rule out depression NOS. Rule out adjustment disorder.
Deferred.
Diabetes mellitus, type 1.
Mild to moderate stressor.
Undetermined at this point.
TREATMENT:
1.
Interview father and mother. Interview Jane again in light of what they
say.
2.
Diabetic education.
3.
Wait until patient is stabilized before investigating further.
4.
Further recommendations will follow.