Reference no: EM133869250

Assignment:

CASE STUDY

Identifying Information: The patient is a 55-year-old male, married, with one daughter, age 22. He holds a BA and MBA degrees in Organizational Management. He is employed full-time but presently is on furlough from his job due to the COVID-19 pandemic creating financial hardship for the company where he has been employed.

Setting: Emergency Room. The patient arrived four hours ago in restraints.

Past Psychiatric History: He has been hospitalized three times on a psychiatric unit, spanning from ages 21 to 32. He was diagnosed with Bipolar I, Manic, at age 21 when he was tried on several psychotropic medications, none of which were particularly effective. At age 32, during his third hospitalization, he was started on Lithium 600 mg PO BID, which has controlled his symptoms fairly well until recently, with no discernible side-effects.

Medical History & Current Medications: (1) Hyperthyroidism, diagnosed at age 26, currently stable with Methimazole 5 mg PO QD, (2) Hypertension, diagnosed at age 47, for which he has been on Metoprolol 100 mg PO QAM & 50 mg PO hs for the past eight years, (3) Seasonal environmental allergies, for which he is prescribed Loratadine 100 mg PO hs for the past two years, (4) Status post-Mitral Valve Replacement, for a diagnosis of Severe Mitral Valve Stenosis as a result of strep throat which he had six months ago; surgery performed five weeks ago; he was hospitalized for seven days. Following surgery, he was placed on Valsartan 80 mg PO QAM & hs, (5) Bipolar I Disorder, for which he is prescribed Seroquel 100 mg PO hs for the past five years, and Lithium 600 mg PO BID

Present Psychiatric Circumstances & History: His psychiatric medications were stopped for unknown reasons upon admission to the hospital for surgery five weeks ago. His behaviors were not unusual while hospitalized. His list of discharge medications did not include Seroquel and Lithium, and he was instructed to follow-up with his psychiatric provider. The earliest appointment he could obtain with his PMHNP was two months out. After two weeks of being at home (the beginning of his third week without psychotropic medications), he began to experience mild difficulty sleeping and developed progressive irritability. At this point, he started arguing with his wife and daughter over very minor matters that he now found to be annoying. At week 3 ½ post-surgery he started yelling and saying that his family was against him as well as other statements of a paranoid character. He started sleeping in the guest room and began staying up most of the night. One morning his wife woke up and found that he took the knives out of the kitchen and lined them up in the living room, along with screwdrivers, hammers, and a sledgehammer from the garage. When his wife inquired about this, he went into somewhat of a rage and said to leave him alone "or else this will turn into a suicide by cop situation, and the dogs will get hurt and you too."

That evening he moved the collection of knives and tools to the garage and basically stayed there most of the following days and nights.

At the beginning of week 4, his daughter called the patient's PMHNP, and she advised that the patient be brought to the Emergency Room and that the wife may wish to call '911'. The patent yelled at his wife when she suggested a trip to the ER, saying the problem was her, not him. Next, a few days later, he called a former coworker and suggested they meet so that the patient could give him some money to help out his friend. When the coworker arrived at the patient's home, the patient told him to get in the car and they'd go get some coffee. Instead, the patient essentially forced the man to run various errands with him for the next four hours while spending large amounts of money, sometimes driving erratically between locations. Upon return to the patient's home, his wife observed the coworker practically jump out of the patient's truck and run frantically to his car. When the daughter inquired what was going on, the patient picked up a weighty object and hurled it at his daughter, narrowly missing her. He returned to the garage for the night.

The following day he came into the house mid-morning and had bought two batons from a military store, as well as mace and pepper spray. He started yelling at his wife, is rubbing his chest as if in pain, and claiming she was having an affair with the next-door neighbor. She said to him, "You must be crazy", at which point he went to the neighbor's home, and when the man opened the door, the patient sprayed him with pepper spray and said that he could hear him and his wife having sex all night long. The patient's wife called '911' as this was happening, and when the police arrived, the patient began to swear and flipped them off. He threatened the cops multiple times and a backup of four more officers was called. The patient was brought to the nearest Emergency Room on an involuntary 72-hour hold in restraints.

CASE STUDY QUESTIONS

(1) What is the current diagnosis for this patient?

(2) What are the differential diagnoses?

(3) Should the patient be prescribed Lithium again? (Why/why not)

(4) What psychotropic medications would you order at this time?

(5) What laboratories would you expect to be ordered in the ER?

(6) What are the implications of the patient being on an involuntary hold?

(7) You have obtained the information about the patient's history from his wife. What information should you now provide to her about his upcoming care?

(8) The wife says that she met the patient after his last (third) psychiatric hospitalization when he was 32 years old and that he has been stable until this episode, but she really does not understand what is Bipolar Disorder and would like to know what this disorder is about and if it is genetic. What education would you provide her?

(9) Including medications, what are the orders you will write for this patient while he is in the ER?

(10) What are two different psychotherapy modalities that may be helpful for this patient once he is home and stabilized? Write one paragraph explaining the basics of each.

(11) Assuming that the patient goes from the ER to an inpatient unit for continued care, what aftercare will he require once discharged from inpatient?