A 26-year-old man is transferred from the medical emergency department to psychiatry after receiving sutures to multiple lacerations on both wrists.
A 26-year-old man is transferred from the medical emergency department to psychiatry after receiving sutures to multiple lacerations on both wrists. The patient was initially brought to the emergency department by a friend who found him in the bathtub, bleeding from his wrists. When the patient is asked to move into an exam room to be interviewed, the examiner notes that he 1st unties and reties his shoes 3 times. When the interviewer finally begins, the patient reports that in recent months he has become disturbed “by his life and the way things are going.” He describes feeling” ugly” and” worthless” and is” tired of dealing with everything”. When asked about his suicide attempt, he states,” the past few days have been really bad… It’s all coming apart now.” He then begins to cry uncontrollably.
When the patient regains composure, that he is a writer who has recently signed a deal to publish novel. He was scheduled to the photographed for the book jacket cover earlier today and feels” overwhelmed” by the idea of being photographed and having the photo publicly released. When asked why he felt overwhelmed, he points to the skin around his mouth, where multiple small lesions in various stages of healing are appreciated. The patient describes an ongoing concern about the thickness of his mustache, despite being clean shaven. He reports shaving 3to 4 times every day and then using tweezers between shaves to prevent more growth. He endorses feeling this way for the past year,” ever since I got my nose fixed.” The patient also admits to repeatedly checking for hair growth in the mirror and feeling that people in the street are constantly looking at his mustache. The patient notes that he lives alone, works from home, and has few friends. He rarely leaves the house because he does not want” to be around people”. He also appears anxious to end the interview and interrupts the examiner to ask if he can go to the bathroom. When asked why, he seems embarrassed but admits to wanting to check his skin and wash his hands.
Past Psychiatric history:
The patient denies any previous psychiatric treatment. He has never been hospitalized or taken psychiatric medication. He was once referred for depressive symptoms but never followed up.
Past medical history:
The patient admits to seeing a dermatologist for” skin problems” and has a history of 2 rhinoplasties in the past 5 years.
Mental status exam:
The patient is a good- looking man who appears his stated age. He is disheveled in appearance but clean shaven. He has limited eye contact, and his speech is slow and quiet. The patient keeps his hand over his mouth throughout the interview and moves it only slightly to speak. When his hand is moved, the lesions around his lips can be seen, and some appear infected. He reports that his mood is “really bad”, and his affect is constricted to the dysphoric range. He cries openly and at times uncontrollably. His thought process is linear and goal directed. He describes feeling that people on the street are looking at him and talking about his skin but denies other disturbance in thought content. He denies homicidal ideation but still endorses suicidal ideation. When asked about a plan, he replies, “well something better than cutting my wrists”. He denies auditory and visual hallucinations. He is alert and orients, with good attention and intact memory and concentration. His insight and judgment appear poor.
Include:
• Any differential diagnoses
• Your diagnosis and reasoning
• Any additional questions you would have asked
• Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
• Any labs and why they may be indicated
• Screener scales or diagnostic tools that may be beneficial
• Additional resources to give (Therapy modalities, support groups, activities, etc.)
CASE 2
49 y/o male
HX of Present Illness:
A 49 y/o male with a history of hypertension and obesity presents to the ER during the evening. He complains of a bad headache, shortness of breath and mild chest pain and is found to have a B/P of 185/120 with apulse rate of 95 but normal respirations. He received clonidine for hypertension, which resolves without incident. The patient describes feeling worried and upset about his blood pressure, which is high again, even though he takes his medication and visits his primary regularly. The provider in the ER suggests speaking to a psychiatric provider about his anxiety.
The Psych NP on call consults with the patient. Over the past year, the patient reports worsening anxiety since being diagnosed with hypertension. He has started exercising and dieting and has reduced his cigarette habit to only 1 cigarette a day. Continued hypertension visits to his primary cause him to worry even more. He fears he will never again gain control of his health and that he may even die. He experiences significant stress about salt and fat in his diet and feels that these thoughts constantly occupy his mind. He also worries about other issues in his life aside from other health concerns, such as driving his car safely and completing details at work. He states that he ruminates about these issues almost all of the time and sometimes has trouble sleeping at night as a result. He reports never feeling rested during the day and at times describes aches and pains in his body.
Lately he has felt even more tense and irritable at work, leading to some arguments with co-workers. He states, that beginning 1 month ago, he began to experience moments of intense fear and panic wondering if he will die. Generally he reports wishing to live his life to the fullest and strongly denies any suicidality. He has a depressed mood at times, however, related to his medical problems and stress, and wonders if his health will ever improve.
Past Psychiatric Hx:
The patient has never received psychiatric care. He states that he has been a somewhat “high-strung person” his entire life but has never felt this kind of anxiety until last year. He denies heavy alcohol or illicit substance abuse. No psychiatric hospitalizations or suicide attempts. He denies any family history of psychiatric illness or substance abuse. He lives with his wife and two preteen boys.
Physical Exam:
Unremarkable except for obesity.
Labs:
CBC and electrolytes are within normal limits, TSH is normal, and cardiac enzymes are not elevated. UA and toxicology screen are negative.
Diagnostic Testing:
EKG shows non-specific S-T abnormalities and no acute changes.
Include:
• Any differential diagnoses
• Your diagnosis and reasoning
• Any additional questions you would have asked
• Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
• Any labs and why they may be indicated
• Screener scales or diagnostic tools that may be beneficial
• Additional resources to give (Therapy modalities, support groups, activities, etc.)
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