Psychiatry Case Presentation
Transcript: Case Synthesis Clinical Assessment & Rationale Treatment Plan 1. Mr. D's medications were adjusted: Increased Trazodone to 100mg PO QHS until discharge (03/15) Increased Remeron to 30mg PO QHS until discharge Added Bupropion 150mg PO QD for 3 days then increase to 300mg Anxiety, dry mouth, hyperventilation, irregular heartbeats, irritability, restlessness, shaking, trouble sleeping Added Atarax 50mg Q4H PO PRN for acute agitation Confusion, drowsiness, dry mouth, hallucinations, headache 2. Patient is encouraged to master coping skills, anger management techniques and relapse prevention strategies. Patient agreed to engage in yoga, exercise & attend community meetings. He will be educated on his medications, diagnoses and will see psychiatrist daily. The patient reported improved mood state, tolerable dental pain. 3. Referred to halfway house before seeing the judge. Patient refused to call them. Mr. D is a 20-year old male with an extensive history of violence who was court-mandated to BRMC's 21-day inpatient treatment program. His DSM-5 diagnoses remains as Personality Disorder NOS, with many cluster B traits. We ruled out bipolar, BPD an schizophrenia as he does not have any hallucinations, delusions, or non-substance induced manic episodes. He most closely resembles that of Antisocial Personality Disorder but his short stay and refusal to complete further personality testing does not allow staff to confirm the diagnosis. The patient was treated with appropriate medications, group and individual therapy. Side effects were tolerated well. Prognosis is fair-poor considering his unwillingness to accept help. Primary: 1. Personality Disorder, NOS F60.9 former conduct disorder, ODD, legal history and repeated violent verbal and physical offenses to others (kicking pregnant teacher, crashing neighbors car) reckless, irritable, complete lack of remorse DDX: 1. Bipolar II F31.81: positive: labile, impulsive, insomnia thoughts of death, worthlessness, diminished ability to think negative: mostly angry, no true hypomania (no gradiosity, pressured speech), substance induced mania, 2. Borderline Personality Disorder F60. 3:: positive: unstable relationships,impulsivity, intense anger, negative: no self-harm, no abandonment issues or paranoid ideation, no unstable identity or emptiness 3. Schizoaffective Disorder F25.9: positive: depressive episodes of <3 days negative: no positive or negative symptoms, Secondary: 1. 1. Cannabis, Opioid & Amphetamine Use Disorder 2. MDD 3. Anxiety Disorder 4. PTSD 5. Asthma Bradford Regional Medical Center Medication ADE Diagnostic Plan Bradford, Pennsylvania Preceptor: Darlene Skaggs Patient Education and Follow Up Remeron (Mirtazapine): Abnormal dreams, back pain, orthostatic dizziness or fainting. increased need to urinate, increased sensitivity to touch, increased thirst, low blood pressure, muscle pain nausea, stomach pain, trembling or shaking or vomiting. Desyrel (Trazodone):Blurred vision, confusion, dizziness, faintness, or orthostatic lightheadedness, sweating, or unusual tiredness or weakness. Penicillin: Nausea, vomiting, diarrhea, rash, abdominal pain, and urticaria. Benadryl: Dizziness, drowsiness, loss of coordination; dry mouth, nose, or throat; constipation, upset stomach; dry eyes, blurred vision; or day-time drowsiness. Nicotine patch transdermal route: Headache, redness, itching, or burning at the application site. Mr. D. will be admitted to the MICA 21-day treatment program to accurately diagnose his psychiatric conditions. He will receive group and individual therapy, medications and arranged with community resources. "This place is bullshit" Remeron 7.5mg PO QHS for MDD and anxiety Trazodone 50mg PO PRN for insomnia Penicillin V 500mg PO TID for tooth abscess that festered in jail Benadryl 50mg PO QHS Nicotine transdermal patch 21mg QD and Nicorette gum 2mg Q2H PO PRN for nicotine withdrawal Benzocaine oral solution for dental pain Mylanta, Tylenol, Motrin, Simethicone and Lactaid PRN Mr. D. became uncooperative and defiant only 8 days shy of his scheduled discharge. He obtained 3 infractions. He also stated racist remarks towards another patient and threatened to "hit the doctor in the face." Despite staff education, Mr. D. left AMA back to jail. His 7-year sentence will not be reduced. Staff report his prognosis as fair to poor. Family support is null. He will receive his current medication regimen in jail. Discharge instructions given and reviewed with patient, including risk of overdose and death. History: History of present illness: Mr. D is a 20 y.o. Caucasian male who is court-mandated to complete BRMC's MICA 21-day treatment program on pre-trial release. Extensive history of arrests related to violence (fights, arsony) and stealing (cars, petty objects) and prior suicide ideation at age 16. Polysubstance use onset at age 9 by parents. Extensive verbal, emotional and physical abuse history, including sexual abuse from biological father beginning at age