Session 2

Psychiatric H&P

Taiba Shah

 

Name: Ashely

D.O.B: 1/5/1993

Age: 27 y.o.

Source of information: Patient and patient’s husband

Patient is questionably reliable

 

CC: Brought in by EMS because patient’s husband called and said “my wife is acting crazy and I’m worried about the baby”

 

HPI: Ashely is a 27 y.o. F with no psychiatric history, 7 days postpartum, who was brought in today by EMS because her husband called stating “my wife was acting crazy and I am worried about the baby.” History was obtained from the patient and her husband. The patient states that she is not sure why she is in the ER and she just want to see her baby. She had an uncomplicated delivery, and her baby girl was full term and healthy. The pregnancy was planned, and the family were excited about the birth. Within two days of delivery Ashely started to sleep less, even when the baby was sleeping and was being taken care of by her husband. She states she sleeps about 2-3 hours a night. She states that she hears voices telling her to take her “newborn baby to the subway and jump in front of a train”. The voices keep her up and worry her. When she told her husband about these voices he called EMS. Her husband also notes that she needs help doing simple tasks like diapering the baby since she gets distracted easily. He says he catches her glaring out the window and mumbling to herself. He reports that he had to stop her from buying a flight to Italy at 3 am the night before. He says she has never acted like this in the past and is usually a responsible person. She breastfed after delivery and the first day postpartum but now she says she thinks her breast milk is poisoning the baby. She says she loves her baby but she feels guilty about having these thoughts and voices. Ashely admits to loss of appetite, suicidal/homicidal ideas, hallucinations, delusions, anxiety and she denies depressive episodes, substance abuse, memory loss, and trauma.

 

Present illness: denies

Pmhx: Asthma- well controlled

Immunizations- up to date

Past surgical history- Appendectomy-3 years ago- no complications

Medications– Prenatal vitamins

Allergies– NKDA

Family history– Mother-Bipolar II disorder, HTN (Deceased- age 54 due to stroke)

Father- Alive and well

1 Daughter, 7 days old

No other significant family history

Social History–

Ashely is a married female, living with her husband and her newborn daughter with no pets. She is an 8^th grade English teacher on maternity leave. She denies alcohol, smoking, and illicit drug use

Travel: No recent travel, diet is less than 3 meals a day

Sleep: 2-3 hours a night for past 5 nights

 

ROS:

Constitutional- decrease in appetite, admits to slight weight change

Skin- No rashes, pruritis, or jaundice.

Head- No headaches or dizziness

Eyes- No vision changes or pain

Ears- No tinnitus or changes in hearing

Nose- No epistaxis, congestion, or rhinitis.

Mouth/Throat- No oral sores, dysphagia, dry mouth or hoarseness.

Neck- No pain or swelling.

Respiratory- No dyspnea, orthopnea, wheezing, or cough.

Cardiovascular- No palpitations, chest pain, or edema.

GI- No recent nausea, vomiting, diarrhea or constipation. No melena or hematochezia

GU- No dysuria, hematuria, nocturia.

Endocrine- No history of diabetes or hypothyroidism. No history of heat or cold intolerance or changes in hair or skin. No polydipsia or polyuria

 

Mental status exam:

Appearance- Patient dressed in pajamas, looks disheveled and has a mild odor. She is distracted and mumbling to herself. Facial expressions are limited and primarily flat.

 

Mood: She describes feeling worried an anxious recently because of the voices. She states at night she feels energetic and happy.

 

Affect: Primarily anxious and is mumbling and fidgeting in her chair. She does smile randomly when talking about her daughter.

 

Speech: Quality shows appropriate tone, volume but slowed at times. Speech is disorganized and incoherent.

 

Thought Content: She lacks obsessions or compulsions. Thoughts involve ruminations about feeling like an inadequate mother. There are thoughts feelings of persecution when she states that the nurses don’t think she is a good mother. She has somatic delusions about her breast milk being poisonous, and reference others thinking she is not a good mother and hallucinations since she hears voices.

 

Cognitive Function:

 

Orientation- She is alert and oriented to person, place, and time. Attention- spelled WORLD forward and backwards without difficulty.

 

Memory- was able to repeat “cat, ball, and lamp,” and recall all three at five minutes. Additionally, was able to list her own birthplace and current address.

 

Language- Able to correctly name a pen and watch.

 

Judgment- stated that she would mail a sealed, addressed, and stamped envelope if he found one lying on the ground.

 

Insight- she was able to talk about her current situation and how she is worried about what the voices are telling her to do. She has poor insight since she strongly believes in her delusions

 

 

Physical Exam

Vitals: T-98.2o F, P-95, R-14, BP-125/85, Ht- 5’3” Wt- 135lbs

Skin: No Cyanosis. No lesions or rashes.

HEENT: Normocephalic, atraumatic head. Oral mucosa is dry but without lesions.

Neck: supple without cervical lymphadenopathy, no JVD, no thyroidomegaly or thyroid masses. Cardiovascular: S1S2, RRR, no murmurs, no gallops. No lower extremity edema.

Lungs: Clear to auscultation. No wheezes, rhonchi, or crackles.

 

Assessment:

Ashely is a 27 y.o. F with no psychiatric history, 7 days postpartum, who was brought in today by EMS because her husband called due to her behavior and he worried about the safety of their child. Before delivery the patient had to history of mood disorder or psychosis. She states she hear voices telling her to jump in front a train with her baby. She believes the nurses are talking about her and how she is as a mother. History and physical findings are suggesting brief psychotic disorder with peripartum onset.

 

 

Plan:

1. Brief psychotic disorder with peripartum onset.
   1. Labs: CBC, CMP, Hepatic panel, TSH, RPR, UA, U Tox, blood alcohol level
   2. Imaging: Head CT
   3. Risperidone starting dose .5 mg/day
   4. Monitor patient and reassess how she responds to medication.
   5. Possible admission

Session 3

Kendra’s Law

 

In 1999 there were multiple events involving individuals with untreated mental illness becoming violent. In one assault in NYC subway, Andrew Goldstein 29 at the time, he had a diagnosis of schizophrenia but he was off of his medication. He pushed Kendra Webdale into the path of an oncoming N train in the 23^rd Street station. He had recently attempted to get treatment but was turned away.

Kendra’s law is a law in New York City has been effective since November 1999 regarding involuntary outpatient commitment also known as assisted outpatient treatment. It was proposed by families of individuals with serious mental health illnesses as a way for their loved ones to get treatment while simultaneously keeping the public safer. The law allows for 2 things:

Judges have the authority to issue orders that require people who meet certain criteria and have a past history of multiple arrests, incarcerations, hospitalizations to regularly undergo psychiatric treatment – Failure to comply can result in containment for up to 72 hours. This law does not mandate that patients be forced to take medication

Before this law, the law required individuals to be so ill they refuse treatment to become dangerous before that can be required to accept treatment. The families that proposed this law believed that dangerous behavior should be prevented rather than required

Kendra’s Law also allows judges to order the mental health system to serve people with serious mental illnesses, instead of choosing the easiest to treat for admission. Kendra’s family played a significant role in getting the law passed. Since passing, this law has been helpful in reducing homelessness, suicide attempts, substance abuse, and physical harm to others.

 

EPS/Tardive Dyskinesia

 

Extrapyramidal symptoms, also called drug induced movement disorders, are the side effects that are caused by antipsychotics and other drugs. Manifestations of extrapyramidal symptoms include akathisia, parkinsonism, and dystonia. All the antipsychotic medications have the potential to cause extrapyramidal symptoms. However, the 1^st generation antipsychotics have a greater potential, examples include haloperidol, fluphenazine, and thiothixene. Monitoring EPS for individuals on antipsychotics is done weekly until the medication dose has been stable for at least 2 weeks.

Akathisia is the most common manifestation of EPS. It presents as motor restlessness. Individuals have a strong urge to move and are unable to stay still.

Parkinsonism includes mask-like faces, resting tremor, cogwheel rigidity, shifting gait, and bradykinesia. Dystonias are involuntary contractions of major muscle groups. They are usually rapid in onset and irritating to patients. When these symptoms are present the first intervention is to lower the antipsychotic dose if possible, with close monitoring of the patient’s exacerbation of psychotic symptoms. Another option is to change the antipsychotic with a different one with less EPS side effects. Beta blockers have been shown to be effective for akathisia, however benztropine have shown a to be effective for all three symptoms of EPS

Tardive dyskinesia is involuntary movements that happened as a result of chronic use of antipsychotics. They usually occur after months of treatment. Movements include sucking, smacking of lips, choreoathetoid movement of the tongue, facial grimacing, lateral jaw movements, movements of the extremities and/or truncal areas. Risk factors include EPS symptoms with acute use of antipsychotics, older age, and long duration of antipsychotic drug. Changing a patient’s antipsychotic with a low risk for TD like quetiapine or clozapine may be useful. Valbenazine and deutetrabenazine are effective in treating abnormal movements in TD.

 

 

Stevens-Johnson Syndrome

 

Stevens-Johnson syndrome is an acute, immune-mediated condition where there is a severe mucocutaneous reaction usually caused by medications. If 10% of the body’s surface area is affected it is considered SJS. Toxic epidermal necrolysis is the more severe form of SJS where greater than 30% of the body is involve and 10-30% is considered an overlap between SJS and TEN. It is characterized by extensive necrosis and detachment of the epidermis. The mucous membranes are affected in over 90% of patients, and usually at 2 more sites such as ocular, oral and genital. SJS is a type 4 hypersensitivity reaction. When the epidermis detaches the body can dehydrate and can even lead to sepsis. Triggers include anticonvulsants like carbamaxepine, antibiotics like sulfonam, some NSAIDs. The risk of SJS/TEN is limited to the first 8 weeks of treatment.  Some infections are also associated with SJS/TEN

Symptoms include fever preceded by one to three days of the development of mucocutaneous lesions, photophobia, conjunctival itching or burning, and pain while swallowing. Patients might develop exanthematous eruption, ill-defined coalescing erythematous macules. The lesions start on the face and thorax before spreading to the extremities. There is positive Nikolsky sign which is a sloughing off by applying gentle lateral pressure on the surface of the skin. Diagnosis is made with history and physical exam findings, and a skin biopsy may be used. Once the diagnosis is made, the severity needs to be established. The SCORTEN score is used to determine prognosis. It involves clinical and lab values. The offending medication must be stopped immediately. These patients are referred to an ICU or burn unit then supportive care is started which includes wound care, fluids, nutrition, pain control, and prevention/treatment of infections.

 

 

 

Serotonin Syndrome

 

Serotonin Syndrome is also referred to as serotonin toxicity. It occurs when there is an increase in serotonergic activity in the CNS. This increase can happen with therapeutic medication use, and drug-drug interactions. It is a life-threatening condition that often includes mental status changes, autonomic hyperactivity and neuromuscular abnormalities. Diagnosis is made with physical exam and history. History should include a detailed description of prescription drugs, over-the counter medications, illicit drug use, some examples of drugs that increase the risk are cocaine, MDMA, SSRIs, Bupropion, St. John’s wort, Fentanyl, Lithium and others. Episodes of serotonin syndrome that involve the use of monoamine oxidase inhibitors may be more severe and life threatening. Patients have a mental status change, such as anxiety, delirium, restlessness and disorientation. They may also have tachycardia, hyperthermia, hypertension, vomiting, muscle rigidity, tremors, and bilateral Babinski sign. Key management included discontinuing the serotonergic agents, supportive care to normalize vital signs, sedation with benzodiazepines, administration of serotonin antagonists, and assessment of the need to continue the serotonergic agent after patient has returned to baseline. Prognosis is favorable as long as it is identified and treated quickly.

 

Sources:

1. https://mentalillnesspolicy.org/kendras-law/kendras-law-overview.html
2. https://www.uptodate.com/contents/serotonin-syndrome-serotonin-toxicity?search=serotonin%20syndrome&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H16
3. https://www.uptodate.com/contents/pharmacotherapy-for-schizophrenia-side-effect-management?search=extrapyramidal%20symptoms&source=search_result&selectedTitle=1~137&usage_type=default&display_rank=1#H28219045
4. https://www.healthline.com/health/symptom/extrapyramidal-symptoms
5. https://www.osmosis.org/learn/stevens-johnson-syndrome
6. https://www.uptodate.com/contents/stevens-johnson-syndrome-and-toxic-epidermal-necrolysis-pathogenesis-clinical-manifestations-and-diagnosis?search=stevens%20johnson%20syndrome&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1